<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001585
Report Date: 12/14/2022
Date Signed: 12/14/2022 05:24:28 PM


Document Has Been Signed on 12/14/2022 05:24 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:LAKEVIEW HOMES MISSION VIEJOFACILITY NUMBER:
306001585
ADMINISTRATOR:ALFONSO VENTURAFACILITY TYPE:
740
ADDRESS:23036 SONOITATELEPHONE:
(949) 583-1213
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:4CENSUS: 4DATE:
12/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Beverlie Moya, caregiver
Gregory Andres, caregiver		TIME COMPLETED:
05:00 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
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on two incident reports received on 11/29/2022 regarding the presence of bruising on the arm and face of client C1, reported by both the facility and the client's day program Vocational Innovation. LPA was greeted and granted entry by caregiving staff after stating the purpose of the visit.

The report transmitted on 11/29/2022 references a previous unreported fall incident that occurred on 11/24/2022. LPA reviewed client records for C1 at the facility, found and made copies of an incident report transmitted to the Regional Center of Orange County on 12/06/2022 indicating "On 11/24/2022 Per Staff Anne Plander Diane accidentally fell down in the backyard when she was trying to use the wheelchair. She was on a kneeling position when they saw her. Staff immediately assisted her to get up and ask her if she's okay and Diane asnwered 'I'm OK'. Body check was done no bruises was noted at that time. On 11/25/2022 at 6:45 am DSP Beverlie noted bruise on Diane's arm when body check was being done". No evidence of a submitted Special Incident Report (SIR) is found in the Regional Office SIR log. When asked about the bruise, caregiver Beverlie Moya describes it as about an inch wide on client's C1 left forearm.

Client C1's Individual Program Plan dated 05/05/2022 makes a reference to yet another incident on 04/01/2022 stating: "On 4/1/22 at 10:00am Diane had an SIR. She was taken to UCI Emergency through 911 with the consent/request of sister/conservator Crista Smith. Diane has been restless/agitated/confused the past few days. According to sister, this can be historically indication of mania and Diane would need acute psychiatric support at at hospital. Diane was taken to UCI accompanied by her sister." No evidence of a submitted Special Incident Report (SIR) is found in the Regional Office SIR log.

CONTINUED ON FORM LIC809-C
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LAKEVIEW HOMES MISSION VIEJO
FACILITY NUMBER: 306001585
VISIT DATE: 12/14/2022
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
26
27
28
29
30
31
32
CONTINUED FROM FORM LIC809

LPA also reviewed resident's daily progress notes from 11/24/22 until 11/29/22. Bruising is noted but no clear explanation of how client received the bruise are present.

LPA was able to observe client C1 relaxing in the facility's living room. Client appeared relaxed, clean and well taken care of. Client also observed smiling and discussing with caregiving staff.

Caregiving staff present is adequately cleared and associated in Guardian.

House manager Sarah Levante is currently stated to be away in the Philippines since approximately 12/08/2022. Administrator Peter Ventura is also unavailable and stated by caregiving staff to be returning on 12/14/2022. In the meantime, administrator duties are covered by Walter Abila. No documentation of the arrangement has been submitted to the Department at this time.

Based on the documents reviewed and observations made during today's visit, one citation is being issued per Title 22 of the California Code of Regulations. A Technical Advisory note is also issued in regards to the provision made in the absence of the facility's designated administrator. An exit interview was conducted and a copy of this report along with appeal rights was provided to facility representative.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/14/2022 05:24 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: LAKEVIEW HOMES MISSION VIEJO
FACILITY NUMBER: 306001585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/14/2023
Section Cited

1
2
3
4
5
6
7
The California Code of Regulations Section 80061 on Reporting Requirements states that "Upon the occurrence (...) of any of the events specified (....) below, a report shall be made to the licensing agency. Events reported shall include the following: Any injury to any client which requires medical treatment.
1
2
3
4
5
6
7
Licensee and administrator will review the cited regulations and ensure that an adequate reporting process is in place for any future incidents.
8
9
10
11
12
13
14
Any unusual incident or client absence which threatens the physical or emotional health or safety of any client." This requirement is not met as evidenced by unreported incidents on 04/01/22 and 11/24/22. This failure to report poses a potential risk to the health and safety of the persons in charge.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3