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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006204
Report Date: 08/28/2024
Date Signed: 08/28/2024 11:57:12 AM

Document Has Been Signed on 08/28/2024 11:57 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVINGFACILITY NUMBER:
306006204
ADMINISTRATOR/
DIRECTOR:
ESPINAL, ALMAFACILITY TYPE:
740
ADDRESS:2025 N BUSH STTELEPHONE:
(714) 541-3357
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY: 130CENSUS: 84DATE:
08/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Erick GonzalezTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Sam Haddadin conducted an unannounced case management visit to follow up on an incident report submitted on 05/31/2024. LPAs were greeted and granted entry into the facility and explained the reason for the visit.

Incident report dated 05/29/2024 indicated Resident 1 (R1) was sent out on a 5150 psychiatric evaluation after allegedly making threats to kill everyone in the facility. Resident was evaluated by psychiatrist and referred for the hold. Resident was sent to LA Downtown Medical Center. Resident has a history of bi-polar, depression, paranoia and anxiety. Resident has not returned to the facility.

LPAs toured the facility and observed residents relaxing and eating lunch. Facility appears clean, safe and sanitary during today's visit.




Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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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