306003838-7-26-2023-22-AS-SSAS-CU89QB-20230729233404

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306003838
Report Date: 07/26/2023
Date Signed: 07/26/2023 04:23:04 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230719125355

FACILITY NAME:	MEISON LA PAZ IV ELDERLY CARE HOME		FACILITY NUMBER:	306003838
ADMINISTRATOR:	HERMELINDA/MIGUEL PEREZ		FACILITY TYPE:	740
ADDRESS:	25371 MAXIMUS		TELEPHONE:	(949) 472-4636
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 4	DATE:	07/26/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Hermelinda Perez, Administrator (via telephone)		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff confiscated resident’s personal cell phone

Staff did not allow resident to have visitors during reasonable hours

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering finding into the investigation of the allegations listed above. LPA was greeted and granted entry by caregiving staff after introducing himself, stating the purpose of the visit and listing the allegations. Administrator Hermelinda Perez was notified of the visit and presented the detailed findings via telephone.

On July 21, 2023, an initial complaint investigation visit was conducted at the facility. LPA accompanied by administrator toured the physical plant. LPA requested and obtained resident records for all residents currently admitted in addition to one resident that had been recently discharged from the facility. Staff records were additionally requested and reviewed. Four resident interviews and three staff interviews were conducted during the visit. Additional witness interviews were led as a follow-up after the visit.

CONTINUED ON FORM LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/19/2023 and conducted by Evaluator Kevin Saborit-Guasch

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230719125355

FACILITY NAME:	MEISON LA PAZ IV ELDERLY CARE HOME		FACILITY NUMBER:	306003838
ADMINISTRATOR:	HERMELINDA/MIGUEL PEREZ		FACILITY TYPE:	740
ADDRESS:	25371 MAXIMUS		TELEPHONE:	(949) 472-4636
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 4	DATE:	07/26/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Hermelinda Perez, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not providing residents with activities while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 22-AS-20230719125355

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: MEISON LA PAZ IV ELDERLY CARE HOME	FACILITY NUMBER: 306003838
	VISIT DATE: 07/26/2023

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
26
27
28
29
30
31
32

CONTINUED FROM FORM LIC9099-A

Regarding the allegation that Staff are not providing residents with activities while in care, the following has been concluded: LPA observed residents relaxing in the facility's television room or in their bedroom. Staff interviewed stated that focused activities were offered based on the resident's personal preferences. Resident interviews conducted were inconclusive on that due to residents' various degrees of cognitive impairment. One witness interviewed stated that "They offer [my mother] activities but they don't push her to participate." Given the facility's licensed capacity, no formal activity schedule is required and there wasn't one on file for LPA to review. As a result, this allegation is deemed to be Unsubstantiated, meaning that although the allegation may have happened or may be valid; there is not a preponderance of evidence to prove that the alleged violation occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 22-AS-20230719125355

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: MEISON LA PAZ IV ELDERLY CARE HOME	FACILITY NUMBER: 306003838
	VISIT DATE: 07/26/2023

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
26
27
28
29
30
31
32

CONTINUED FROM FROM LIC9099

Regarding the allegation that Staff confiscated resident personal cell phone, the following has been concluded: Residents R1, R2, R3 and R4 all stated during confidential interviews that they did not utilize personal cell phones at the facility and that they typically received phone calls on the facility's phone line. Resident R1 additionally stated that she had the ability to request staff to call her family members for her and was confirmed to make the request on a frequent basis by two out of three staff members interviewed. An additional witness interview determined that R1 was initially provided with a phone with a simplified interface by her daughter but that usage was terminated after the device was shown to create distress for the resident. As a result, the allegation is found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

Regarding the allegation that Staff did not allow resident to have visitors during reasonable hours, the following has been concluded: Admission agreements reviewed are shown to include the following provision regarding the facility's visit policy: "Visiting hours: The facility encourages regular visits from family, friends and clergy. Facility visitors or volunteers and others may be subject to criminal records clearance. (The facility is allowed to make the final determination.) Please feel free to visit from 8:00am until 7:00pm every day. Should you require other visiting times, please contact the facility administrator in advance to make arrangements. We are flexible regarding visitation." Interviews conducted with staff, residents and witnesses all corroborated the fact that visits are facilitated in accordance with the policy quoted above. Therefore the allegation is found to be Unfounded, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted and a copy of this report was provided to a facility representative.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4