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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000408
Report Date: 09/01/2022
Date Signed: 09/01/2022 01:22:58 PM


Document Has Been Signed on 09/01/2022 01:22 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, 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:
09/01/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Facility Administrator-Carmen Rivas TIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC 809D on 08/04/2022. NOTE: POC date was extended to 8/25/22. LPA De Perio explained reason for visit and was greeted and granted entry by facility administrator (AD) Carmen Rivas. For today's visit, LPA De Perio verified that there are currently 4 residents in care, of which 1 is on hospice and there are 2 staff members on duty.

On 08/04/22, LPA De Perio observed that there was no Administrator Certificate posted, along with conducting an interview with facility administrator via phone who stated that certificate expired in February 2022, and stated that no renewal fee has been submitted.

*Deficiency cited under Title 22 Regulation 87407(e) pertaining to Administrator Certification Requirements has been CLEARED. Licensee has submitted and provided documentation indicating that the following have been completed:

(1) A completed Application for Administrator Certification form LIC 9214


(2) Evidence of completion of the required continuing education hours as specified in section 87407(a) or 87407(g), if applicable. The total number of hours required to complete if they had remained certified. The date of computation shall be the date application for renewal is received by the Department's Administrator Certification Section.
(3) Payment of a non-refundable delinquency fee equal to three times the one hundred dollar ($100) renewal fee, or three hundred dollars ($300).
(4) A copy of the front and back of his/her current nursing home wallet license, or equivalent, if the applicant is a current Nursing Home Administrator.
Licensee has complied with the terms of the POC.

LPA De Perio conducted an exit interview with AD Rivas and a copy of this report and Letter of Cleared Deficiency has been provided to the facility.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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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