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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003634
Report Date: 02/07/2023
Date Signed: 02/07/2023 03:02:10 PM


Document Has Been Signed on 02/07/2023 03:02 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CASA DEL LAGOFACILITY NUMBER:
306003634
ADMINISTRATOR:RIVERO, LOURDESFACILITY TYPE:
740
ADDRESS:27332 ALLARIZTELEPHONE:
(949) 716-4497
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 3DATE:
02/07/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Lourdes Rivero, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced inspection visit for the purpose of issuing a citation for an observed deficiency. LPA was greeted and granted entry by caregiving staff after explaining the purpose of the visit. Administrator Lourdes Rivero was notified by telephone and arrived later to assist with the visit.

On February 1, 2023, LPA conducted an initial complaint investigation visit at the facility. During the visit, staff records were reviewed and noted to be incomplete in the case of two staff members, S1 and S2. Health screening forms and tuberculosis screening were noted to be absent in the files of the two most recent hires.

On February 7, 2023, Administrator emailed Health Screening forms for both staff members. Both physician reports are dated from February 2, 2023. Staff member S1 has a hire date on file of September 12, 2022 and staff member S2 has a hire date of August 1, 2022. The health screenings have therefore been conducted outside of the required period of a maximum of seven days following hire.

Based on interviews conducted and records reviewed, one type B citation is issued per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights were provided and left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/07/2023 03:02 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CASA DEL LAGO
FACILITY NUMBER: 306003634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2023
Section Cited

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All personnel (...) shall be in good health(...). Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment.
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Licensee scheduled health screenings for staff members S1 and S2 on the day following the initial inspection visit conducted on 02/01/23.
All staff have been screened for good health at the time of the present visit, deficiency cited and cleared during the visit.
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This requirement is not met as evidenced by health screening forms provided by facility administrator which are dated 02/02/2023 for two of the three staff members currently employd at the facility.
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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: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2