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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200327
Report Date: 05/10/2022
Date Signed: 05/10/2022 12:08:54 PM

Document Has Been Signed on 05/10/2022 12:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:LORRIE RESIDENTIAL CARE HOME IVFACILITY NUMBER:
435200327
ADMINISTRATOR:ANGELINA ESCOBARFACILITY TYPE:
740
ADDRESS:675 HIGH GLEN DRIVETELEPHONE:
(408) 923-2784
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 5DATE:
05/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Angelina EscobarTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a case management visit regarding an incident involving resident (R1) elopement from the facility. LPA met with Angelina Escobar Administrator and toured the facility inside and out.

Incident report states on 4/21/22 R1 was gardening in the backyard at 1:45pm. At 2:00pm staff did not see R1 in the backyard and went searching for R1. Administrator called the police to report a missing person. Police arrived at the home to take a report, when S1 called and reported S1 found. R1 was one block away. The police called 911 and R1 was transported to the hospital. R1 sustained injuries to face and hand. R1 was discharged back to the facility at 10:00pm with instructions to follow up with medical doctors. On 5/10/2022 stiches above right eye removed. The Administrator understood no Police Report was written.

R1 had resided at the facility for approximately 2 months. R1's family home is located a couple of blocks away. On one occasion after R1 moved in, he wanted to visit his family home and was shadowed by staff . Staff remind R1 that he cannot not leave the facility without staff but to let them know and staff will make arrangements for R1 to go out.

R1 stated that R1 wanted to get something to eat, so R1 left the facility and had a fall.

LPA advised the Department will review the information provided to conclude the incident case management.

This report was reviewed with Angelina Escobar Administrator and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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