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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001585
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:03:16 PM


Document Has Been Signed on 10/30/2023 02:03 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: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: 3DATE:
10/30/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Karen Zambrano, Sarah LevanteTIME COMPLETED:
01:30 PM
NARRATIVE
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On today’s date, Licensing Program Analyst (LPA) Sean Haddad conducted an unannounced visit for the purpose of delivering findings on the investigation of a self-reported incident report received in the Orange County Regional Office (OCRO) on 04/24/23. LPA was greeted and granted entry into the facility and met with Staff #1 (S1) Karen Zambrano and House Manager Sarah Levante.

During course of the investigation, the Department interviewed staff and residents as well as reviewed and obtained pertinent documentation. Regarding the allegations of physical abuse and failure to seek timely medication / lack of care, the following was concluded:

Resident #1 (R1) was admitted to the facility on 12/14/17. Per facility face sheet dated 07/18/22, R1 has diagnoses of Bipolar I Disorder with Psychotic Features and Mild Intellectual Disability.
On 04/24/23, the OCRO received a self-reported incident report stating that on 04/18/23, at approximately 1300 hours, R1 called out from their room. Staff #1 (S1) and Staff #2 (S2) found R1 on the floor and assisted R1 from the floor. Staff assessment did not reveal any "apparent injury." R1 advised S1 they fell on the floor and complained about pain and was given Tylenol. The fall was not witnessed. House Manager (HM) Sarah Levante instructed S1 and S2 to observe R1 throughout the day. On the evening of 04/18/23, Staff #3 (S3) observed a bruise on R1’s right top shoulder but reported that R1 was not in any pain. R1 also reported to S3 and Staff #4 (S4), "I fell on the floor ... I don't want to get up ... I don't want to go to day program” and that S1 dragged and pulled them. This was reported to Administrator Peter Ventura who instructed S3 and S4 to observe R1 through the night and that he would assess R1 in the morning. The following afternoon, 04/19/23 at 1630 hours, Administrator Peter Ventura arrived at the facility, assessed R1, was told by R1 that they fell on the floor and rolled “on” the bed, but reported R1 was not aware of when the fall occurred or what they were doing prior to the fall. R1 was transported to Saddleback Family Urgent Care on 04/19/23, was seen at 1758 hours, and x-rays diagnosed R1 with a closed fracture of the right clavicle. The incident was self-reported within the 48-hour requirement.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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: LAKEVIEW HOMES MISSION VIEJO
FACILITY NUMBER: 306001585
VISIT DATE: 10/30/2023
NARRATIVE
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The interviews conducted consistently show that S1 has not used physical force with the resident even though the resident reported being pulled by staff. The facility staff that was present refute this information and stated that R1 was in another room alone when the incident occurred. Moreover, the resident has a history of lying and in subsequent interviews denied being assaulted by S1. There is not enough information to support the allegation of physical abuse.

Based on the preponderance of evidence gathered through multiple interviews and documents obtained; the allegation “physical abuse” has not been met; Therefore, this allegation is deemed to be UNSUBSTANTIATED.

However, it was determined that S1 uses their voice to redirect the residents. It was corroborated that S1 shouts at residents.

When interviewed, S1 admitted to not calling 9-1-1 when they discovered that the resident had an unwitnessed unforeseen fall. S2 wanted to call 9-1-1 but, was prevented from doing so because S1 took the phone from them while speaking with their supervisor, HM. HM then instructed S2 to only observe the resident until the following day. HM admitted staff should have contacted emergency services. There is sufficient information to support the allegation of failing to seek timely medical attention.

Based on the preponderance of evidence gathered through multiple interviews and documents obtained; the allegation “failure to seek timely medication / lack of care” has been met; Therefore, this allegation is deemed to be SUBSTANTIATED.

The facility is being cited per Title 22, Division 6 of the California Code of Regulations. Immediate civil penalties are being assessed. See LIC421IM. An exit interview was conducted with House Manager Sarah Levante and a copy of this report, along with LIC809-D, Appeal Rights, LIC421IM, and the LIC 811, identifying confidential names were provided at exit.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/30/2023 02:03 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: LAKEVIEW HOMES MISSION VIEJO
FACILITY NUMBER: 306001585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2023
Section Cited
CCR
87465(g)

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87465 Incidental Medical and Dental Care … (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health… This requirement was not met as evidenced by:
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Licensee stated they will conduct training for staff on responding to resident injuries and calling 9-1-1 and will submit proof to LPA by POC due date.
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Based on interviews and documents, on 4/18/2023 the facility did not call 9-1-1 immediately after R1’s fall and injury and only took R1 to urgent care the next day, which posed an immediate health risk to persons in care. CIVIL PENALITY ASSESSED.
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Type A
10/31/2023
Section Cited
CCR87468.2(a)(8)

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87468.2 … Personal Rights … (a) … (8) To be free from … intimidation, and verbal, mental … abuse. This requirement was not met as evidenced by:
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Licensee stated they will conduct training for staff on proper interactions with residents and submit proof to LPA by POC due date.
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Based on interviews, the licensee did not ensure residents are not shouted at by staff, which poses an immediate personal rights risk to persons in care.
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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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
LIC809 (FAS) - (06/04)
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