306000408-8-4-2022-22-AS-CDPO-CGYQPH-20220804122045

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000408
Report Date: 08/04/2022
Date Signed: 08/04/2022 12:20:53 PM

Document Has Been Signed on 08/04/2022 12:20 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 #2		FACILITY NUMBER:	306000408
ADMINISTRATOR:	RIVAS, CARMEN T.		FACILITY TYPE:	740
ADDRESS:	25231 MAMMOTH CIRCLE		TELEPHONE:	(949) 472-3811
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 4	DATE:	08/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:27 AM
MET WITH:	Staff on Duty-Elizabeth Ferrer		TIME COMPLETED:	12:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 2 staff were on duty, who contacted facility administrator (AD) Carmen Rivas about visit. AD Rivas provided consent for staff on duty (S1) Elizabeth Ferrer to conduct tour, sign and receive report, due to AD Rivas being unavailable and having to attend a medical appointment. As of 8/2/22, there are no active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted in the hallway of the facility. The PUB475 "See Something, Say Something" poster was also observed to be located in the hallway. LPA De Perio toured the interior and exterior portions of the facility with S1. The facility is a single level structure and is licensed for 6 non-ambulatory residents, 0 bedridden and 2 hospice . Currently, there are a total of 4 residents in care, of which 1 is on hospice. All 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. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured at 106.4 degrees Fahrenheit and hand washing signs were also posted in each restroom.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

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: 08/04/2022

NARRATIVE

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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, mounted and located in the kitchen. For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which both were self-closing and self-latching. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the hallway of the facility. Facility had back-up emergency food and water supply, located in the garage.

LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the living room. Medications were locked and located in a kitchen cabinet. Toxins were also observed to be locked and inaccessible to residents.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with S1. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service 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 video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPA De Perio advised S1 and AD Rivas to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with S1 and AD Rivas via phone call and a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/04/2022 12:20 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
CCLD Regional Office, 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: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87407(e)

87407 (e) Administrator Certification Requirements This requirement is not met as evidenced by: (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 to complete if they had remained certified. The date of computation shall be the date application for renewal is recieved 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
1 2 3 4	Based on observation of not observing an Administrator Certificate posted, and interview with facility administrator via phone who stated that certificate expired in February 2022, no renewal fee has been submitted, and disclosing the knowledge about the expired certificate, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/18/2022
	Plan of Correction
1 2 3 4	Licensee will submit the proof on or by 8/18/2022 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. NOTE: Due to Administrator not being able to be present to sign report, consent was provided for staff on duty to sign on her behalf. Citation was read via phone to Administrator who acknowledged and agreed to comply with the items discussed.

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: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC809 (FAS) - (06/04)

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