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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000289
Report Date: 08/20/2024
Date Signed: 08/20/2024 12:03:54 PM

Document Has Been Signed on 08/20/2024 12:03 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LAGUNA PALMSFACILITY NUMBER:
306000289
ADMINISTRATOR/
DIRECTOR:		MICHAEL MILOFACILITY TYPE:
740
ADDRESS:24571 KINGS ROADTELEPHONE:
(949) 859-7929
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 5DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:06 AM
MET WITH:Michael MiloTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Co-Administrator Julieta Santiago and explained the reason for the visit. Michael Milo's Administrator's Certificate expires on September 6, 2025. Facility is licensed for 6 non-ambulatory residents with a hospice waiver for 2 residents. 2 residents are currently on hospice. LPA and the Co-Administrator toured the facility. Facility is a single story home with 6 bedrooms, 1 staff room, 4 bathrooms, living room, family room with a screened fireplace, dining room, kitchen and a 2 car garage. Smoke detectors/carbon monoxide detectors tested operational. LPA observed the PUB 475, See Something, Say Something was not posted but was leaning on entrance wall. LPA observed all resident rooms have the required furnishings and bed linens. LPA observed the fire extinguisher in the kitchen is fully charged. There is a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Knives are kept locked in a kitchen drawer. Medications are kept locked in a kitchen cabinet. LPA inspected the first aid kit. The first aid kit has all the required elements. All 4 bathrooms are clean and operational. Hot water measured from 108.2 to 109.0 degrees Fahrenheit in all bathrooms. LPA toured the garage. The garage is kept locked and used for storage. LPA observed emergency food and water, tools and supplies in the garage. LPA toured the backyard. LPA observed ladders, dirt and rocks on the side of the North side of house which creates an obstacle leading to the exit gate to the front of the house. The Co-Administrator reported that the side of the house is having the stucco repaired and the process has not been completed. LPA observed a fountain in the backyard. There is a pergola with chairs and a table to sit outside. There is a walkway on the South side of the house leading to the front courtyard. In the front courtyard there is a shaded patio and a fountain. LPA reviewed 5 resident files. 3 out of 5 residents did not have a current Appraisal/Needs and Service Plan. LPA reviewed 5 resident medications, no discrepancies observed. LPA reviewed 2 staff files, no discrepancies observed. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Co-Administrator Julieta Santiago refused to sign the report (LIC 809 & LIC 809D) including the deficiency page (LIC 809D) per advise from her attorney. An exit interview was conducted and a copy of the report along with appeal rights was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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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Document Has Been Signed on 08/20/2024 12:03 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 08/20/2024 at 11:50 AM
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: LAGUNA PALMS
FACILITY NUMBER: 306000289

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 5 residents which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee agrees to complete new appraisals/needs and service plans for the 3 residents and to submit proof to the LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024


LIC809 (FAS) - (06/04)
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