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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005633
Report Date: 02/15/2024
Date Signed: 02/15/2024 10:27:57 AM

Document Has Been Signed on 02/15/2024 10:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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: 5DATE:
02/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Frances Umali- AdministratorTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Jessica Cho continued the visit after delivering the findings in connection to Complaint Control Number: 22-AS-20231103161201. LPA stated the purpose of the visit to Administrator Frances Umali.

During the course of the complaint investigation mentioned above, LPA discovered that the Department did not receive a written report pertaining to the two falls Resident #1 (R1) suffered on October 17, 2022 and November 2, 2023. LPA obtained copies of the two incident reports on today's date.

As a result of today’s Case-Management visit, a Technical Advisory note (LIC9102) will be issued.

An exit interview was conducted with Frances Umali, and a copy of this report including the LIC9102 and LIC811 were provided at exit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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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