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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001615
Report Date: 10/14/2024
Date Signed: 10/14/2024 04:46:10 PM


Document Has Been Signed on 10/14/2024 04:46 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:MEISON LA PAZ ELDERLY CARE HOMEFACILITY NUMBER:
306001615
ADMINISTRATOR:MIGUEL PEREZFACILITY TYPE:
740
ADDRESS:24332 TWIG STREETTELEPHONE:
(949) 454-6184
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 6DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Hermelinda PerezTIME COMPLETED:
05:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Administrator Hermelinda Perez and explained the reason for the visit. LPA observed the See Something Say Something Poster (PUB 475) posted in the entry way of the facility. The Administrator, Hermelinda Perez's Administrator's certificate expires on October 30, 2024. LPA and Administrator toured the facility. The facility is a 2 story house with 5 bedrooms, living room, kitchen, dining room, 3 bathrooms and a 2 car garage. The facility is licensed for 6 non-ambulatory residents, hospice waiver for 2, no bedridden allowed. LPA observed both bathrooms are clean and operational. The hot water measured 109.4 degrees Fahrenheit. LPA observed all resident rooms had the required furnishings and bed linens. The smoke detectors/carbon monoxide detectors tested operational. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The 4 burner gas stove lights unassisted. LPA observed the knives and sharp objects are kept locked in a kitchen drawer. LPA observed the garage is kept locked and used for storage of supplies, extra food and emergency food and water. LPA observed the medication is kept locked in a cabinet in the garage. LPA toured the backyard. LPA observed there is a plastic shed in the backyard. The shed is used for storing extra furniture and kept locked. The exit gates leads to the front courtyard. No bodies of water observed. There is shaded seating in the backyard. No obstacles or hazards observed in the backyard. LPA toured the second floor of the facility. No residents live upstairs. There are 2 bedrooms upstairs and 1 bathroom. LPA reviewed 2 staff files, no discrepancies observed. LPA reviewed 6 resident files and medications, no discrepancies observed. There is no facility record of an emergency disaster drill taking place in the last 3 months. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024
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 10/14/2024 04:46 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: MEISON LA PAZ ELDERLY CARE HOME
FACILITY NUMBER: 306001615

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above] which poses a potential health and safety risk to persons in care.
POC Due Date: 10/24/2024
Plan of Correction
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Licensee agrees to have an emergency drill by the POC due date and to forward proof to the LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024
LIC809 (FAS) - (06/04)
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