306001615-9-23-2022-22-AS-CDPO-CJJSX6-20220923141524

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001615
Report Date: 09/23/2022
Date Signed: 09/23/2022 02:15:32 PM

Document Has Been Signed on 09/23/2022 02:15 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:	MEISON LA PAZ ELDERLY CARE HOME		FACILITY NUMBER:	306001615
ADMINISTRATOR:	MIGUEL PEREZ		FACILITY TYPE:	740
ADDRESS:	24332 TWIG STREET		TELEPHONE:	(949) 454-6184
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY:	6	CENSUS: 6	DATE:	09/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Facility Administrator - Hermelinda Perez		TIME COMPLETED:	02:25 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	Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 2 staff were on duty, who contacted facility administrator (AD) Hermelinda Perez about visit. As of 9/23/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted at the entrance of the facility. The PUB475 "See Something, Say Something" poster was also observed at the entrance. LPA observed the Administrator's Certificate for Heremelinda Perez which expires on 10/30/22. AD Perez provided documentation to LPA De Perio that renewal fee has been submitted and courses have been completed. LPA De Perio toured the interior and exterior portions of the facility with AD Perez. The facility is a 2 level structure and is licensed for residents 60 years and over, of which 6 may be non-ambulatory, 0 bedridden, and hospice waiver was granted for 2 hospice residents . For this visit, there are a total of 6 residents in care, of which 1 is on hospice, and 0 are bedridden. There are a total of 3 bedrooms downstairs for residents, of which there are 3 shared rooms and no private rooms. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. LPA De Perio toured second level of facility and observed no residents residing on the second floor. There are 2 bedrooms on the second floor and 1 bathroom. LPA De Perio observed and verified with AD Perez that second level is not for resident use and is utilized for AD Perez's family. LPA De Perio reviewed fingerprints and background check for live-in family members, of which both members are cleared.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

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: MEISON LA PAZ ELDERLY CARE HOME	FACILITY NUMBER: 306001615
	VISIT DATE: 09/23/2022

NARRATIVE

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Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 2 restrooms on the first level and 1 on the second level. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 106.8 degrees Fahrenheit and hand washing signs were also posted in each restroom.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were located in a kitchen drawer and locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in by the main entrance door.

LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the hallway of the facility. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in garage. Medications were located in a locked cabinet located in the garage, of which the garage is also locked. Toxins were also observed to be locked and inaccessible to residents and located in the garage.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There is 1 gate that is shared between the front yard and backyard, which was self-closing and self-latching. No bodies of water were observed.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Perez. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

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: MEISON LA PAZ ELDERLY CARE HOME	FACILITY NUMBER: 306001615
	VISIT DATE: 09/23/2022

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LPA De Perio discussed with AD Perez to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

LPA De Perio discussed the California Code of Regulations Section 87466 Observation of the Resident and Section 87211 Reporting Requirements with AD Perez.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio advised AD Perez to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Perez and a copy of this report and copies of the regulations discussed were provided to the facility.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerio	TELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC809 (FAS) - (06/04)

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