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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005633
Report Date: 12/14/2023
Date Signed: 12/14/2023 12:44:19 PM

Document Has Been Signed on 12/14/2023 12:44 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:MARYKNOLL SENIOR CAREFACILITY NUMBER:
306005633
ADMINISTRATOR:UMALI, FRANCES AMANDAFACILITY TYPE:
740
ADDRESS:531 WHITTEN WAYTELEPHONE:
(805) 836-1556
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 4DATE:
12/14/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Facility Administrator- Amanda UmaliTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced case management visit to the facility and explained reason for the visit to facility administrator (AD) Amanda Umali.

During the tour of the physical plant of the facility for complaint: 22-AS-20231211163815. LPA observed resident 1 (R1) room sealed and secured by the Placentia Police Department. LPA conducted record reviews and observed that AD completed and submitted a report to the Orange County Community Care Licensing Regional Office dated for 11/28/23.

For today's visit, no citations were issued.

An exit interview was conducted with AD.

A copy of this report was provided and explained.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
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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