306001585-10-30-2023-22-AS-SHAD-CX4UZJ-20231030160136

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001585
Report Date: 10/30/2023
Date Signed: 10/30/2023 04:01:54 PM

Document Has Been Signed on 10/30/2023 04:01 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 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:	10/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Karen Zambrano		TIME COMPLETED:	04:15 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	This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting a Required – 1 Year Inspection. LPA met with Staff #1 (S1) Karen Zambrano and discussed the purpose of the inspection. House Manager (HM) Sarah Levante arrived during the inspection. Administrator (AD) Peter Ventura appeared via telephone. LPA reviewed Infection Control requirements. At about 2:00PM, LPA and HM conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: this is a one-story home. Facility is a 4-bedroom, 3-bathroom, one-story house with an attached garage that is being used for storage. LPA observed 2 staff and 3 residents present at the facility. Resident Bedrooms: the 4 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: there are no staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested at 119.3 degrees F in the common client bathroom and 119.6 in the private client bathroom. LPA inspected all rooms in the facility. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the kitchen and in the garage. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. LPA discussed licensing fees with AD. At about 3:00PM, LPA reviewed 3 resident files and 2 staff files, interviewed 3 residents and 2 staff, and inspected medications for 3 residents. CONTINUED.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (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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Document Has Been Signed on 10/30/2023 04:01 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on documents, the licensee did not ensure 2 out of 2 staff completed the 40-hour initial or 20-hour annual training, which poses a potential safety risk to persons in care.
	POC Due Date: 11/27/2023
	Plan of Correction
1 2 3 4	Licensee stated they will have staff complete the training and submit proof to LPA by POC due date.

Type B

Section Cited

CCR

87303(a)

Type B: CCR 87303(a) – 87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. … for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and documents, the licensee did not ensure the facility contained a fire extinguisher inspected within the last year, which poses a potential health and safety risk to persons in care.
	POC Due Date: 11/27/2023
	Plan of Correction
1 2 3 4	Licensee stated they will have the fire extinguisher inspected or replaced immediately and submit proof to LPA 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: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (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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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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During the inspection, LPA and HM observed the following: Per staff files, S1 and S2 did not complete the 40-hour initial or 20-hour annual training. The facility has 2 fire extinguishers, but neither was inspected in the last year.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean Haddad	TELEPHONE: (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)

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