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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002987
Report Date: 02/13/2024
Date Signed: 02/13/2024 12:35:28 PM


Document Has Been Signed on 02/13/2024 12:35 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:MISSION VIEJO CARE COTTAGES 2FACILITY NUMBER:
306002987
ADMINISTRATOR:MIGUELITO "BING" FAJARDOFACILITY TYPE:
740
ADDRESS:24142 DELPHI STREETTELEPHONE:
(949) 297-8948
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
02/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Miguelito FajardoTIME COMPLETED:
12:50 PM
NARRATIVE
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This unannounced Case Management – Incident inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of a health and safety check and to follow up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 01/30/24 regarding an incident involving Resident #1 (R1). LPA met with Administrator (AD) Miguelito Fajardo and discussed the purpose of the inspection.

During today’s inspection, LPA toured the facility with AD and observed 2 staff and 6 residents present. LPA conducted health and safety checks on the residents present and observed no health and safety issues. LPA observed the facility to be clean and organized and found no health and safety issues. 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, the electricity and water were running, the facility had soap and paper towels, and the medications, sharps, and toxins were properly stored. LPA interviewed AD and requested and reviewed copies of the resident roster, staff roster, R1’s resident file, R1’s Kaiser Medical Records dated 01/16/24, and R1’s Kaiser Medical Records dated 01/27/24.

Per AD, on 01/13/24 at 12:20AM, R1 had an unwitnessed fall. R1 was assisted by staff and assessed by AD and reported no pain. While facility staff were trying to transport R1 to urgent care on 01/13/24 at around 2PM, R1 complained of a high level of pain and could not be transported due to the pain, so 9-1-1 was called around 3PM. Per Kaiser Medical Records dated 01/16/24 and 01/27/24, R1 was later diagnosed at the hospital with multiple rib fractures. The facility did not obtain medical attention timely for R1.

Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. A technical violation regarding resident records is also being issued. 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 LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
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 02/13/2024 12:35 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: MISSION VIEJO CARE COTTAGES 2
FACILITY NUMBER: 306002987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/12/2024
Section Cited
CCR
87465(g)

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87465 Incidental Medical and Dental Care … (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health… This requirement was not met as evidenced by:
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Licensee stated they will conduct training for staff on responding to resident injuries and calling 9-1-1 and will submit proof to LPA by POC due date.]
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Based on interviews and documents, on 01/13/24 the facility did not call 9-1-1 immediately after R1’s fall and injury and only tried to take took R1 to urgent care the next day, which posed a potential health risk to persons in care.
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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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 02/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/13/2024
LIC809 (FAS) - (06/04)
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