Reata Glen Orange County CCRC

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Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Ruth Martinez, Hanna Gough and Nancy Guillen conducted an unannounced visit to Reata Glen. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is a Continuing Care Retirement Facility licensed for 840 residents of which 10 may be on hospice. There are 675 residents admitted with 4 on hospice on today's visit. Kelly Conk has an administrator certificate is current. LPAs along with facility management team began the tour of the facility. LPAs toured the physical plant, checked food service, facility records and the medication room. Facility appears to be clean, safe, and sanitary. Facility consists of 300 units in the main building, 98 units in the villas and 82 units in garden terrace. Throughout the property, LPAs observed multiple outside areas, two restaurants, a "Grab and go" market, fitness area, theater, billiards room, putting green, pickle ball court, activity areas and a secured swimming pool/ jacuzzi. Resident apartments had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident restrooms were checked. Toilets and water faucets worked properly, and shower was free of mold/mildew. Water temperature measured between 112.8 and 120 degrees F in facility resident bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. Emergency lighting, and facility telephone were all working. LPAs reviewed medication administration and storage. Medications are stored in a locked medication cart. Medications are being CONTINUED ON LIC 809-C administered per physician order First aid kit had required elements including thermometer, tweezers and scissors where observed in the medication room. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility is keeping a log of freezer/ refrigerator temperatures and were within range. Smoke detectors and fire inspections are conducted by an outside company, with the last inspection date in April 26, 2026. Fire extinguishers are fully charged with service date April 23, 2026. LPAs observed evacuation chairs at stairwells. LPAs observed ample emergency food and water as well as ample emergency supplies. LPAs reviewed the emergency disaster plan and infection control plan during the visit. Plans are thorough and complete. Facility conducts quarterly emergency drills with the last drill conducted on April 28, 2026. Facility provides activities in the form of games, exercise, and outings in the community. LPAs observed residents participating in activities during the visit. LPAs toured the outside parameters and did not observed any obstructions. LPA Martinez observed a indoor swimming pool with an outdoor space with a fence around it. LPA observed the pool gate has a self-latching entry door which opens towards the spa pool. The fence has a key lock at the gate door for inaccessibility. LPA measured the pool fence which measured 6.8ft from base of the floor to the top of the fence and it was observed to enclose the entire pool area. LPA observed the pool has one entry doors throughout the spa pool area. LPAs observed no health or safety concerns during the visit. LPAs reviewed 15 select resident and 6 staff files. Resident files contained required documents. Staff files reviewed contained required documentation such as health screen/TB and first aid/CPR. LPAs received a current copy of the certification of liability insurance with expiration date of June 30, 2027. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the Senior Executive Director/Administrator and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jul 7, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on a death report submitted to the department on 04/21/2026. LPA was greeted and granted entry into the facility and explained the reason for the visit. Death report dated 04/20/2026 indicated Resident 1 (R1) had fallen in the resident's apartment and the fall activation device was activated. The facility safety team responded and 911 was called. Resident was sent out to Mission Hospital via paramedics where the resident was declared deceased at 1:00 PM. R1's family indicated the resident had a brain bleed. Per Resident's service plan dated 12/29/2025, Resident is independent of activities of daily living and not considered a fall risk. Resident is self responsible. Per physician report dated 08/02/2021 resident is diagnosed with Diabetes Mellitus 2. Administrator to forward a copy of the death certificate upon receipt. During the visit, LPA observed and spoke with residents in the facility. Residents expressed satisfaction with facility services. LPA observed no health or safety concerns during the visit. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Apr 23, 2026

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on a death report submitted to the department on 02/13/2026. LPA was greeted and granted entry into the facility and explained the reason for the visit. Death report dated 02/05/2026 indicated Resident 1 (R1) had passed away at Providence Mission Hospital after a witnessed fall in the resident's room. R1 was utilizing the walker when she turned and let go in front of the care companion. R1 had 24 care companions on site. The resident was transferred to the hospital where the resident passed away diagnosed with a subdural hematoma with left pelvic fracture from a mechanical fall. Resident was on hospice care with a diagnosis of malignant neoplasm brain. Facility has been attempting to get a copy of the coroner report and will forward it to LPA upon receipt. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Mar 24, 2026

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Kimberly Lyman and Andrea Mendivil conducted an unannounced visit to Reata Glen. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs were allowed entry into the facility and explained the reason for the visit. Facility is a Continuing Care Retirement Facility licensed for 840 residents of which 6 may be on hospice. There are 664 residents admitted with 2 on hospice. Kelly Conk has an administrator certificate expiring on 06/17/2026. LPAs Lyman and Mendivil along with facility management team toured the facility at 12:45 PM. LPAs toured the physical plant, checked food service, facility records and the first aid kit. Facility appears to be clean, safe, and sanitary. Facility consists of 326 units in the main building, 78 units in the villas and 76 units in garden terrace. Throughout the property, LPAs observed multiple outside areas, two restaurants, a "Grab and go" market, fitness area, theater, billiards room, putting green, pickle ball court, activity areas and a secured swimming pool/ jacuzzi. Resident apartments had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident restrooms were checked. Toilets and water faucets worked properly, and shower was free of mold/mildew. Water temperature measured between 114 and 118 degrees F in facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had required elements including thermometer, tweezers and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility is keeping a log of freezer/ refrigerator temperatures and were within range. Smoke detectors and fire inspections are conducted by an outside company, Fire Protection Specialties INC with the last inspection date in May 2025. Fire extinguishers are fully charged. LPAs observed evacuation chairs at stairwells. CONTINUED ON LIC 809C DATED 07/01/2025. LPAs observed ample emergency food and water as well as ample emergency supplies. LPAs reviewed the emergency disaster plan and infection control plan during the visit. Plans are thorough and complete. Facility conducts quarterly emergency drills with the last drill conducted on 04/04/2025. Facility provides activities in the form of games, exercise, and outings in the community. LPAs observed residents participating in activities during the visit. LPAs observed no health or safety concerns during the visit. LPAs reviewed select resident and staff files. Resident files contained required documents including current physician reports and resident appraisals. Staff files reviewed contained required documentation such as health screen/TB and first aid/ CPR. LPAs reviewed medication administration and storage. Medications are stored in a locked medication cart. Medications are being administered per physician order. Based on observations made during today's visit, NO deficiencies are being cited. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 1, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPA) Amy Rodgers conducted an unannounced Required One Year visit to ensure substantial compliance with Title 22 regulations. This facility is co-licensed as a Continuing Care Retirement Community (CCRC) for up to 840 elderly residents. LPA was granted entry into the facility and was met by Executive Director (ED) Kelly Conk with whom LPA discussed the purpose of the visit. LPA was accompanied by Executive Director Conk, during a tour of the facility, which was conducted inside and out including a sample of resident units, the dining area, recreation rooms, outside grounds, and food storage areas. Exterior and interior passageways were free from obstructions. Pathways were free of obstruction and slip hazards. There is an indoor pool securely locked and accessible by key card to residences. There are waters featured throughout the facility that are only accessible to independent residents. Smoke and carbon monoxide alerts are hard wired to a central location. All doors and elevators were operational. Emergency lighting, and facility telephone were all working. Fire extinguisher(s) were in working order. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. Each resident had clean and sufficient bed linens. All extra linens towels, and washcloths are all accessible in rooms or in locked facility storeroom. All residents’ rooms were equipped with required furnishings. Lighting was present in the bedrooms. Residents’ bathrooms were observed to be sanitary and operational. Toilets and showers were equipped with grab bars. [CONTINUED ON LIC 809-C] CONTINUED FROM 809] Facility has a two-day supply of perishable food and a seven-day supply of nonperishable food items. Food supply is replenished frequently by outside vendors. Food was observed to be properly stored and labeled. The food service area was observed to be neat and clean. Food menus and activities schedule were posted and available through the facility communication application. Central cleaning supplies were stored in a locked closed room. Centrally stored medications were properly stored and locked in medication carts. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions. Staff records review verified that all staff records are complete and compliant. LPA conducted a thorough review of In-service training procedures. All direct care staff have current First Aid and CPR training and Community employes EMTs as safety officers. Resident records reviewed and confirmed compliant. Administrator’s certification is current. LPA interviewed multiple staff and clients. The interviews did not raise any significant licensing concerns. LPA reviewed the theft and loss policy and procedures. Transportation procedures are compliant. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. No deficiencies were observed or cited during today's annual inspection. An exit interview was conducted, this report was discussed with Executive Director Conk. The report along with Licensee/Appeal Rights (LIC 9058 01/2106), and their signature on this form acknowledges receipt and a copy of the report was given to Executive Director Conk.the state’s words, verbatim · CDSS document, Aug 8, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced case management visit to follow up on a death report received by the department on 07/12/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. Death report dated 07/07/2024 indicated Resident 1 (R1) was found on floor by husband around 8:48 AM. Husband called facility safety unit who responded within 2 minutes. 911 was called and compressions were started on resident. OC Fire and Sheriff responded and took over CPR. Resident was declared deceased at 9:18 AM. OC SD DR#24-022499 and Coroner Report #24-03692. Resident was independent of services. Per facility protocol, Resident checked in with facility around 6:45 AM on 07/07/2024. Physician report dated 10/22/2020 indicated resident is diagnosed with Hypertensive Disorder and Appraisal Needs and Services indicates chronic Atrial Fibrillation. Facility to forward a copy of the death certificate upon receipt from family. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 16, 2024