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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000408
Report Date: 06/28/2022
Date Signed: 06/28/2022 11:42:05 AM


Document Has Been Signed on 06/28/2022 11:42 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:LAKE FOREST COUNTRY HOME #2FACILITY NUMBER:
306000408
ADMINISTRATOR:RIVAS, CARMEN T.FACILITY TYPE:
740
ADDRESS:25231 MAMMOTH CIRCLETELEPHONE:
(949) 472-3811
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 4DATE:
06/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Facility Administrator- Carmen RivasTIME COMPLETED:
12:11 PM
NARRATIVE
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to Lake Forest Country Home #2 to conduct a case management (CM) visit. The purpose of this CM visit was to gather facility files in regards to the incident reported by facility administrator (AD) Carmen Rivas.

LPA De Perio arrived at facility at 10:14 AM and was granted entry by staff on duty. LPA observed a total of 4 residents in care. LPA toured the interior portions of the facility with staff and resident. AD arrived at 10:33 AM and provided LPA copies of the following documents:
  • SOC 341 (completed and provided LPA hard copy)
  • Admission Agreement
  • Resident file
  • Staff file
  • Emergency contact for resident
  • Staff training
  • Resident roster
  • Personnel report
  • Employee rights
  • Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders
  • Criminal Record Statement
  • Appraisal/Needs and Services Plan
  • Personal Possession Liability Release
  • LIC 602
  • Copy of written check provided by resident
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LAKE FOREST COUNTRY HOME #2
FACILITY NUMBER: 306000408
VISIT DATE: 06/28/2022
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LPA De Perio conducted interviews and file reviews during visit.

Due to time constrains, this case management visit will be completed at a later time.

There were no deficiencies issued during this Case Management visit. No citation was issued during this visit.

An exit interview was conducted with Licensee/Administrator Carmen Rivas and a copy of this report was provided at the time of this visit.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC809 (FAS) - (06/04)
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