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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000408
Report Date: 09/27/2024
Date Signed: 09/27/2024 01:08:00 PM


Document Has Been Signed on 09/27/2024 01:08 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: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: 5DATE:
09/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Rosdiana Sitanggang-Caregiver, Carmen Rivas-AdministratorTIME COMPLETED:
01:22 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Samer Haddadin conducted an unannounced visit for the Required 1 Year Inspection. LPAs explained the purpose of today’s visit, and were greeted and granted entry by Caregiver Rosdiana Sitanggang. Administrator (AD) Carmen Rivas arrived shortly after.

For today’s visit, LPAs observed a total of five residents in care and two staff members on duty.

LPAs observed the Administrator's Certificate for facility AD Carmen Rivas which expired on February 2022; a Deficiency was issued today.

LPAs toured the interior and exterior portions of the facility with Caregiver Sitanggang. The facility is a one-story structure and is licensed for six non-ambulatory residents, of which three may be on hospice and zero bedridden. There are a total of six bedrooms, of which five are resident bedrooms, and one is a bedroom for staff. LPAs toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of three full restrooms and one half restroom. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 108.5-112.8 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged and located by the kitchen.

During today's visit LPAs observed resident having a tuna sandwich, chicken soup, fruit and juice for lunch.

CONTINUED ON LIC809-C...

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LAKE FOREST COUNTRY HOME #2
FACILITY NUMBER: 306000408
VISIT DATE: 09/27/2024
NARRATIVE
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LPAs observed the emergency disaster and evacuation plan which is located by kitchen/dining room. Facility had back-up emergency food and water supply. LPAs observed that First Aid Kit had all the required components. LPAs observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPAs observed a shaded area, patio furniture, and the grounds were free of any hazards. There are two gates in the backyard, which both are self-closing and self-latching. No bodies of water were observed.

LPAs reviewed five resident and three staff files. LPAs interviewed residents and staff present.

For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPAs advised AD Rivas to use the general email address:


CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

An exit interview was conducted with AD Rivas.

A copy of this report was provided at the time of exit.

SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/27/2024 01:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: LAKE FOREST COUNTRY HOME #2
FACILITY NUMBER: 306000408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.319(a)
Regulations
(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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Licensee to provide one internet access device and email LPA proof by POC date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee to email proof to LPA by POC due date.
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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 09/27/2024 01:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: LAKE FOREST COUNTRY HOME #2
FACILITY NUMBER: 306000408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87407(e)
This requirement is not met as evidenced by: 87407
Administrator Recertification Requirements
(e) To apply for recertification after the expiration date of the certificate, but within four (4) years of the certificate expiration date, the certificate holder shall submit to the Department’s Administrator Certification Section:
(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 for recertification shall be determined by computing the number of continuing education hours the certificate holder would have been 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.
Deficient Practice Statement
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Based on nterview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Based on observation of not observing an Administrator Certificate posted, and interview with facility administrator who stated that certificate expired in February 2022, no renewal fee has been submitted
POC Due Date: 10/11/2024
Plan of Correction
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Licensee will submit the proof on or by 10/11/2024 to Community Care Licensing (CCL) and inform the assigned Licensing Program Analyst (LPA) of the needed materials to show that certificate renewal is in the process.

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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4