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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006204
Report Date: 12/13/2023
Date Signed: 12/13/2023 02:34:46 PM

Document Has Been Signed on 12/13/2023 02:34 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:WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVINGFACILITY NUMBER:
306006204
ADMINISTRATOR:ESPINAL, ALMAFACILITY TYPE:
740
ADDRESS:2025 N BUSH STTELEPHONE:
(714) 541-3357
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY: 130CENSUS: 58DATE:
12/13/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Alma EspinalTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit in conjunction with complaint visit 22-AS-20231122171857. LPA was greeted and granted entry into the facility and explained the reason for the visit.

During the course of the complaint investigation, LPA toured the facility and interviewed Administrator and witness. Resident 1 has a power of attorney acting as agent for the resident concerning healthcare decisions. LPA reviewed the power of attorney paperwork and confirmed the designation. Administrator confirmed knowledge of resident having a power of attorney for decisions however indicates the paperwork may have been displaced in the facility. Administrator acknowledges the resident was signed up for hospice care at the facility but indicates not being sure of the circumstances surrounding the enrollment and lack of notification to responsible party. Hospice agency was provided resident's personal information without release from responsible party. Resident was disenrolled from hospice after responsible party was advised of the decision via a third party agency.

Based on the observations made from today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the Administrator and a copy was provided to Administrator as well as Appeal Rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
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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Document Has Been Signed on 12/13/2023 02:34 PM - It Cannot Be Edited


Created By: Kimberly Lyman On 12/12/2023 at 01:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVING
FACILITY NUMBER: 306006204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2023
Section Cited
CCR
87405(d)(1)

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The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7).... Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not being met as evidenced by:
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Licensee to submit a statement of understanding to LPA by POC due date.
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Based on interviews conducted and record review, Licensee failed to ensure facility has a qualified administrator. Facility administrator is not aware of what is occurring in facility and not managing resident's private information. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023


LIC809 (FAS) - (06/04)
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