306000589-9-11-2024-22-AS-JCHO-D8ZQ7C-20240911115454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000589
Report Date: 09/11/2024
Date Signed: 09/11/2024 11:55:04 AM

Document Has Been Signed on 09/11/2024 11:55 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BRIGITTE'S VILLA REGINA HOME		FACILITY NUMBER:	306000589
ADMINISTRATOR:	MARK FISK		FACILITY TYPE:	740
ADDRESS:	24331 SPARTAN		TELEPHONE:	(949) 770-2702
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	09/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:00 AM
MET WITH:	Mark Fisk & Erin Fisk- Administrators		TIME COMPLETED:	12:20 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 Analysts (LPAs) Jessica Cho, Jerome Haley, Samer Haddadin arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPAs were greeted by Caregiver Cristy Lucero and were granted entry. Administrator Mark Fisk arrived on premise approximately 8:15am and Erin Fisk arrived shortly after. The Administrator's Certificate for Mark Fisk expires on January 27, 2026 Facility is licensed to serve six (6) non-ambulatory residents and maintains an approved hospice waiver of (4) residents. There are six (6) residents in care during today's visit with two (2) caregivers on duty. LPAs conducted a tour of the physical plant. This is a single story home in a residential neighborhood. The facility consists of six resident bedrooms and four resident bathrooms. There is an additional bedroom occupied by two live-in caregivers. LPAs inspected all common areas including the garage. The garage door was observed to be locked and LPAs were not allowed access into the garage. After several discussions with Administrators Mark and Erin of ensuring LPAs having full access within the property line, LPAs were allowed entry approximately 9:40am. LPA Haley and Haddin observed the garage was filled with clutter. Photographs were taken. The residents' bedrooms were appropriately furnished. Beds and bedding supplies were in good condition, adequate lighting was provided, sufficient storage space for personal belongings were observed. Bathrooms were found to be clean, sanitary, and operational. The water temperature measured at 118.5, 118.4, 118.7, and 115.8 degrees Fahrenheit. Toxins and disinfectants were unsecured in a pail under the dresser in the hallway. Medications were secured and inaccessible. LPAs observed sufficient two day supply of perishables and seven day supply of non-perishable food. Caregiver #1 (C1) was reminded to label the expiration dates of the pantry items in lieu of the opening date. LPAs toured the exterior portion of the facility. LPAs observed the outdoor passageway. Admins cleared the two bicycles that were obstructing the passageway as well as the shovel and metal bar.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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 09/11/2024 11:55 AM - 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: BRIGITTE'S VILLA REGINA HOME	FACILITY NUMBER: 306000589
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs' observations, three bottles of disinfectants were left unsecured in a pail underneath the dresser in the hallway which poses a potential Health, Safety, or Personal Rights risk to persons in care. Disinfectants were removed immediately.
	POC Due Date: 09/18/2024
	Plan of Correction
1 2 3 4	Administrators stated that an Acknowledgement of Understanding of the said regulation will be submitted to LPA via email by POC due date.

Type B

Section Cited

CCR

87456(a)(3)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs' observations and record review, administrator did not obtain a recent medical for one out of the six residents in care which poses a potential Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 09/25/2024
	Plan of Correction
1 2 3 4	Administrators stated that the physician's report will be updated for R5 and will provide proof to LPA via email 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: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BRIGITTE'S VILLA REGINA HOME	FACILITY NUMBER: 306000589
	VISIT DATE: 09/11/2024

NARRATIVE

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LPAs observed sufficient seating and shading. There was no body of water. Facility maintains a fire extinguisher which was mounted, charged, and serviced on October 4, 2023. The auditory devices and smoke/carbon monoxide detectors were tested and operational. LPAs observed sufficient PPE and emergency disaster supplies including food/water. Emergency evacuation drills are conducted quarterly and facility is maintaining a log documenting the drills. The first aid kit contains all necessary elements. LPA observed the required 'See Something, Say Something' (PUB475) poster in the correct size posted in the entry way. Facility maintains a current liability insurance. A working facility telephone number, (949)-998-9191, was tested and remains available.

LPAs conducted an audit of six residents' files and two personnel files. A discrepancy was noted for Resident #6 (R6). Medications were audited for six residents. No discrepancies noted. Staff and resident interviews were also conducted.

The following items were consulted with Administrator Mark and Erin: to ensure LPA(s) have full access within the property line moving forward, to post the No-Smoking, Oxygen in use sign on the front door and bedroom door for Resident #5 (R5), to ensure disinfectants are secured and inaccessible to all residents, to remove the clutter in the garage, and to update the physician's report for Resident #6 (R6).

Based on the observations made during today's visit, deficiencies are being cited as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. See the attached LIC9099-Ds. Advisory Notes are also being issued.

An exit interview was conducted with Administrators Mark and Erin Fisk, and a copy of this report including the LIC9099-C & Ds, LIC421IM, Advisories, and the Appeal Rights were provided at exit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 09/11/2024 11:55 AM - 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: BRIGITTE'S VILLA REGINA HOME	FACILITY NUMBER: 306000589
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews, the garage was filled with clutter without a clear passageway which poses a potential Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 09/30/2024
	Plan of Correction
1 2 3 4	Administrator stated that the clutter will be cleared and organized and will provide proof to LPA via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

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