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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005352
Report Date:
12/06/2021
Date Signed:
12/29/2021 06:28:34 PM
Document Has Been Signed on
12/29/2021 06:28 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:
DIGNITY & WISDOM
FACILITY NUMBER:
306005352
ADMINISTRATOR:
TESFAY, SABA
FACILITY TYPE:
740
ADDRESS:
17331 VINEWOOD AVENUE
TELEPHONE:
(714) 368-9058
CITY:
TUSTIN
STATE:
CA
ZIP CODE:
92780
CAPACITY:
6
CENSUS:
5
DATE:
12/06/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:03 PM
MET WITH:
Licensee Saba Tesfay.
TIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a case management visit to follow up on SIR received on 12/3/21. LPA was greeted and granted entry into the facility by Licensee Saba Tesfay.
New resident Abdul Hamed SimJee was admitted to the facility by Silverado Hospice on 11/28/21 to the facility and resident passed away on 11/29/21. Resident reside at the facility for one day.
LPA obtained copy St. Joseph Hospital discharged peppers. Admission agreements. Based on St. Joseph Hospital resident passed away due to End-stage Alzheimer’s dementia.
No citations noted during today's visit. Exit interview conducted and a copy of this report was provided
.
SUPERVISORS NAME
:
Marina Stanic
LICENSING EVALUATOR NAME
:
Shobhana Frank
LICENSING EVALUATOR SIGNATURE
:
DATE:
12/06/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
12/06/2021
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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