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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002559
Report Date: 03/06/2024
Date Signed: 03/06/2024 04:19:30 PM


Document Has Been Signed on 03/06/2024 04:19 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:LAGUNA PALMS IIFACILITY NUMBER:
306002559
ADMINISTRATOR:MICHAEL G. MILOFACILITY TYPE:
740
ADDRESS:29501 VIA SAN SEBASTIANTELEPHONE:
(949) 429-6397
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 5DATE:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Michael Milo, Julieta Milo TIME COMPLETED:
04:35 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 Administrators Michael Milo and Julieta Milo explained the reason for the visit. LPA and Administrator Julieta Milo toured the facility. Facility is a one story home with 8 bedrooms, living room, 7 bathrooms, kitchen, dining room and a two car garage that is kept locked and used for storage. There is a fountain in the front courtyard. Capacity is for 6 residents. Two rooms are for staff. LPA observed all resident rooms had the required furnishings. LPA observed all bathrooms were clean and operational. Hot water in the bathrooms measured 116.0 degrees Fahrenheit. LPA observed the kitchen is clean and organized. LPA observed the medications are kept locked in a kitchen cabinet. There is a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. There is a small fountain in the backyard. The backyard connects to the front yard on each side of the house. The front yard is fenced and has a gate. There is a sitting area with a table and chairs in the front court yard. No obstacles or hazards observed inside or outside of the facility. LPA observed all fire extinguishers are fully charged. Carbon monoxide and smoke detectors tested operational. LPA inspected the first aid kit. The first aid kit had all the required elements. LPA reviewed 2 staff and 5 resident files. LPA observed 2 out of 5 residents did not have current physician's reports (LIC 602A). Resident 1 (R1) has been diagnosed with Dementia and their LIC 602A was dated December 20, 2022 and Resident 2 (R2) has been diagnosed with Dementia and their LIC 602A was dated December 14, 2022. No other discrepancies observed. Based on the observations made during today’s visit deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.

An exit interview was conducted and a copy of the report ( LIC 809) provided along with citations (LIC 809D) and appeal rights. Administrator refused to sign the report (LIC 809 & LIC 809D).
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
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 03/06/2024 04:19 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: LAGUNA PALMS II
FACILITY NUMBER: 306002559

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of persons with dementia. Licensees who accept and retain residents with dementia shall ensure that each resident with dementia has an annual medical assessment (MA) and a reappraisal done at least annually.

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 in 2 out of 2 residents diagnosed with Dementia, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2024
Plan of Correction
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Licensee to get new updated physician reports (LIC 602As) for Resident 1 and Resident 2. Licensee to forward copies of the new physician reports to LPA by 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: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024
LIC809 (FAS) - (06/04)
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