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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200327
Report Date: 06/21/2021
Date Signed: 06/21/2021 02:37:13 PM

Document Has Been Signed on 06/21/2021 02:37 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, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:LORRIE RESIDENTIAL CARE HOME IVFACILITY NUMBER:
435200327
ADMINISTRATOR:ANGELINA ESCOBARFACILITY TYPE:
740
ADDRESS:675 HIGH GLEN DRIVETELEPHONE:
(408) 923-2784
CITY:SAN JOSESTATE: CAZIP CODE:
95133
CAPACITY: 6CENSUS: 6DATE:
06/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Angelina EscobarTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Joanne Roadilla conducted an unannounced Case Management visit at the facility today. The facility is licensed to serve 6 residents 60 years and over, 5 may be non-ambulatory and 1 may be bedridden. The facility has been granted a hospice waiver for two (2). LPA met with Administrator (ADM) Angelina Escobar and discussed the purpose of the visit.

On 06/08/21, ADM submitted a request to retain a resident (R1) who has been diagnosed as bedridden and with an unstageable pressure injury. On 06/20/21, ADM sent an updated request to include that R1 is dependent on others for all activities of daily living.

At 2:00PM, LPA observed R1 in bedroom #5. LPA observed that R1 is not able to reposition and is bedridden. LPA also observed that R1 was able to eat without caregiver assistance.

At 2:30PM, LPA reviewed R1's files including physician's reports (LIC602A), appraisal/needs and services plan (LIC625) and functional capability assessment (LIC9172). Per R1's most recent physician's report, R1 is dependent on all activities of daily living and is non-ambulatory.

LPA requested a copy of R1’s LIC625 upon admission and a copy of R1’s updated LIC602A which should indicate that R1 is bedridden for the purpose of fire clearance.

No deficiencies cited during today's visit. Report was discussed with and a copy provided to Angelina Escobar.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Joanne Roadilla
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2021
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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