306001585-10-16-2024-22-AS-KSGH-DA4VAK-20241016161604

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001585
Report Date: 10/16/2024
Date Signed: 10/16/2024 04:16:56 PM

Document Has Been Signed on 10/16/2024 04:16 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:	LAKEVIEW HOMES MISSION VIEJO		FACILITY NUMBER:	306001585
ADMINISTRATOR:	ALFONSO VENTURA		FACILITY TYPE:	740
ADDRESS:	23036 SONOITA		TELEPHONE:	(949) 583-1213
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	4	CENSUS: 3	DATE:	10/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:55 PM
MET WITH:	Sarah Levante, House Manager		TIME COMPLETED:	04:20 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	On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. House manager Sarah Levante was notified of the visit via telephone and arrived later to assist with the visit. LPA accompanied by staff conducted a tour of the physical plant and observed the following: the facility is a one-story home with an attached garage. The facility has four bedrooms, one of which is designated for use by an ambulatory resident. The fire clearance allows for three bedridden residents however none of the residents are bedridden at the time of the visit. There are two bathrooms on the premises, both observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. Bathrooms faucets and toilets are operational. Water temperature was measured at 117.5F. LPA observed all beds have linen and blankets. There are half rails used for postural supports in two of the private bedrooms. Physician orders for both residents reviewed. There are currently three residents admitted to the facility upon placement from the Regional Center of Orange County. None of the residents are receiving hospice care. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. The facility is however still using the outdated LIC610E form in spite of the Advisory Note provided on that topic during the previous annual inspection conducted on October 30, 2023. Type B citation issued. Drills are conducted quarterly and documented. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke and carbon monoxide detectors tested operational. Fire extinguisher present is fully charged and has been maintained in 2023. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

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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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: LAKEVIEW HOMES MISSION VIEJO	FACILITY NUMBER: 306001585
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468(c)(2)(A)

Personal Rights of Residents

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation conducted during the tour of the physical, the licensee did not comply with the section cited above as the posted notice is not the mandated size, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2024
	Plan of Correction
1 2 3 4	Licensee will replace the poster with a version in the adequate size and inform LPA of the replacement before the plan of correction 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: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/16/2024 04:16 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: LAKEVIEW HOMES MISSION VIEJO	FACILITY NUMBER: 306001585
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(a)(2)

Other Provisions

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as the one-page version of the Emergency and Disaster Plan LIC610E is still observed to be in use which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/15/2024
	Plan of Correction
1 2 3 4	Facility staff stated they would update the current Emergency and Disaster Plan onto the current form LIC610E and provide a copy of the plan to LPA before the plan of corrections 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: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

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: LAKEVIEW HOMES MISSION VIEJO	FACILITY NUMBER: 306001585
	VISIT DATE: 10/16/2024

NARRATIVE

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CONTINUED FROM FORM LIC809
There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on each side of the property. The routes of egress are free of obstructions.

Medication, cleaning products and sharp items are confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed to be accurate and up to date with the resident's prescription orders.

LPA reviewed three resident files along with ten staff files. Resident records include all necessary components. All staff members on the facility's roster are confirmed to be cleared and associated with this particular licensed location. Training and CPR training verified to be up to date, with proof of orientation training and in-services observed to be on file. Five staff members are observed to have completed the DSP Year One or Year Two training. Health screenings are on file for all staff members. Infection control plan reviewed.

Personal rights poster PUB475 is observed to be posted on an 8x10 sheet in spite of the Advisory Note provided during the previous annual inspection. Type B citation issued.

Based on the observations made during today’s inspection, two type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

LIC809 (FAS) - (06/04)

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