306003634-1-31-2024-22-AS-JCHO-CZZTNL-20240131135255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003634
Report Date: 01/31/2024
Date Signed: 01/31/2024 01:53:08 PM

Document Has Been Signed on 01/31/2024 01:53 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:	CASA DEL LAGO		FACILITY NUMBER:	306003634
ADMINISTRATOR:	RIVERO, LOURDES		FACILITY TYPE:	740
ADDRESS:	27332 ALLARIZ		TELEPHONE:	(949) 716-4497
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 3	DATE:	01/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ana Maria Martinez- Caregiver		TIME COMPLETED:	02:20 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) Jessica Cho arrived unannounced for the purpose to conduct the Required 1-Year Annual Inspection. LPA was greeted and granted entry after stating the purpose of the visit to Caregiver Veronica Gastelum. Administrator (Admin) Lourdes Rivero was not present to assist with the facility inspection on today's date. LPA spoke to the Admin by telephone and consented Caregiver Martinez to sign the report on her behalf. LPA conducted a tour of the physical plant accompanied by Caregiver Martinez, and the following was observed: This is a single story facility comprised of four resident bedrooms and three resident bathrooms, laundry room, living/family room, dining room, and a two-car garage. LPA toured the outside grounds. There was shading and sufficient seating for the residents. The exit gates were self-closing and self-latching. LPA observed three residents and two caregivers on duty. The resident bedrooms are spacious and easily accommodates the residents' furnishings. Furniture for each resident bedrooms were inspected. The bathrooms were clean, faucets, toilets, and grab bars were operational. The hot water temperature initially measured at 133.7 in the private bathroom, 131.5, and 127.4 degrees Fahrenheit in the shared bathroom. The water heater was readjusted and corrected during the visit which then measured at 117.6, 116.2, and 118.9 degrees Fahrenheit. There were sufficient supply of clean linens. LPA observed a two-day supply of perishables and a seven-day supply of non-perishable food as required per egulation. Carbon monoxide, smoke detectors, and the auditory devices were tested and operational except in Bedroom #1. Caregiver Martinez was unable to reach and test the two smoke detectors located in the hallway by the entrance and in the master bedroom. The fire extinguishers were serviced on 04/07/23. Medications and sharps were locked and inaccessible to the residents. Toxins in the laundry room and under the sink were not secured at the time of inspection. Facility had ample supply of emergency supplies including food/water. LPA reviewed three out of the three resident files and two out of the two staff files including the resident medications.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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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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: CASA DEL LAGO	FACILITY NUMBER: 306003634
	VISIT DATE: 01/31/2024

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LPA is reminding the following: Licensee to pay the licensing fees due on 03/30/2024, to ensure at least one staff on duty with a CPR/First Aid training is on premise at all times, to submit a recording of the testing of the (2) smoke detectors, to repair/replace the smoke detector in Bedroom #1, to replace (1) magnetic lock to the left sink cabinet, to ensure the laundry room is locked at all times, to complete the missing sections of the LIC610E (Emergency and Disaster Plan), to notify the Department designating a facility representative during the administrator's absence, to accurately document when the medication was refused on the Medication Administration Record (MAR), and to dispense the medications matching the corresponding date.

Based on the observations made during today's visit, a deficiency is being cited as per the Title 22 Division 6 Chapter 2 of the California Code of Regulations. Advisory Notes (LIC9102s) were also issued during the visit.

An exit interview was conducted with Caregivers Ana Maria Martinez and Veronica Gastelum, and a copy of this report including the LIC809C, and the LIC9102ss were provided at the end of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/31/2024 01:53 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: CASA DEL LAGO	FACILITY NUMBER: 306003634
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

1569.618 (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews, and record review, the licensee did not comply with the section cited above for two out of the two caregivers at the time of inspection which poses a potential health, safety, or personal rights risk to persons in care.
	POC Due Date: 02/12/2024
	Plan of Correction
1 2 3 4	Licensee to submit proof of CPR/first aid training for all staff to LPA via email by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC809 (FAS) - (06/04)

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