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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000415
Report Date: 08/13/2024
Date Signed: 08/13/2024 01:14:09 PM


Document Has Been Signed on 08/13/2024 01:14 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:OASIS HOME FOR THE ELDERLYFACILITY NUMBER:
306000415
ADMINISTRATOR:FORERO, CRISTO A.FACILITY TYPE:
740
ADDRESS:23471 BLUE BIRD DRIVETELEPHONE:
(949) 454-9188
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:4CENSUS: 3DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Olga Moreno, Cristo ForeroTIME COMPLETED:
01:15 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 Administrator Olga Moreno and Cristo Forero and explained the reason for the visit. The facility is a two story home with 5 bedrooms, 3 bathrooms, living room, dining room, kitchen and a 2 car garage. Facility has a capacity for 4 non-ambulatory residents and a hospice waiver for 1. The second floor is for live in staff. The second floor has 3 bedrooms and 2 bathrooms. Residents only reside on the first floor. LPA observed the See Something, Say Something poster posted in the hallway measures 8 1/2 by 11 inches. LPA observed the Ombudsman poster posted next to the stairway. The Administrator's Certificate expires on December 18, 2024. LPA Observed the fireplace in the living room is screened. The smoke detectors tested operational. The carbon monoxide detector in the living room tested operational. The facility does not have internet service at this time. LPA observed the bathroom downstairs for residents is clean and operational. Hot water measured 116.2 degrees Fahrenheit. LPA observed the kitchen is clean and organized. Knives are kept locked in the kitchen cabinet. LPA observed medications are kept locked in the kitchen cabinet. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. The 4 burner gas stove lights unassisted. LPA reviewed 2 staff files. No discrepancies observed. LPA reviewed 3 resident files. LPA observed Resident 3 (R3) did not have a current appraisal/needs and service plan. No other discrepancies observed. LPA reviewed 3 resident medications, no discrepancies observed. LPA and Administrator toured the backyard. No bodies of water observed. There is a shade patio area to sit outside. The exit gate is operational. LPA inspected the garage. The garage is kept locked and used for storage. LPA inspected the first aid kit. The first aid kit has all the required elements. LPA consulted with the Administrator concerning reporting requirements. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulation. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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 08/13/2024 01:14 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: OASIS HOME FOR THE ELDERLY
FACILITY NUMBER: 306000415

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024

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 1 out of 3 residents (R3 did not have a current appraisal/needs and service plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/27/2024
Plan of Correction
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Licensee agrees to have a new appraisal/needs and service plan for R3 by the POC due date. Licensee to forward proof of correction to LPA.
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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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