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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000889
Report Date: 02/29/2024
Date Signed: 02/29/2024 03:20:58 PM

Document Has Been Signed on 02/29/2024 03:20 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SENIOR LIVING COMMUNITY FOR THE EASTERN STAR IN CAFACILITY NUMBER:
306000889
ADMINISTRATOR:KAT FARRISFACILITY TYPE:
741
ADDRESS:16850 E. BASTANCHURY ROADTELEPHONE:
(714) 577-9281
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 76CENSUS: 28DATE:
02/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Kat FarrisTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit to follow up on an incident report received by Community Care Licensing on 2/27/2024. LPA met with Executive Director (ED) Kat Farris and explained the reason for the visit.

Incident report indicated that on 2/24/2024 Resident 1 (R1) missed a dose of medication. Medication had originally been ordered on 2/20/2023.

During interviews, Director of Wellness (DW) Lida Spicer stated medication dose was missed due to medication not being delivered by the pharmacy. DW and ED denied having any additional related incidents.

During today’s visit, LPA obtained copies and reviewed pertinent documentation including R1's centrally stored medication record, R1's Medication Administration Record (MAR) for February 2024, medication request dated 2/17/24, and emergency request sent by facility Licensing Vocational Nurse (LVN) on 2/24/24.
Per R1's centrally stored medication record, medication dose which was missed is of one capsule to be taken routinely by mouth before breakfast. Per medication request record, medication was requested on 2/17/24 to be approved on 2/20/24. Per R1's MAR, medication was missed on 2/24/24 and 2/25/24. LPA was provided with proof of emergency request submitted by LVN on 2/24/24. Medication was refilled the evening of 2/25/24 and R1 resumed medication on 2/26/24. R1's MAR indicated medication has been taken routinely since 2/26/24 and no further action is required.

Based on observations made during today's inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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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