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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003838
Report Date: 05/29/2024
Date Signed: 05/29/2024 04:57:17 PM


Document Has Been Signed on 05/29/2024 04:57 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:MEISON LA PAZ IV ELDERLY CARE HOMEFACILITY NUMBER:
306003838
ADMINISTRATOR:HERMELINDA/MIGUEL PEREZFACILITY TYPE:
740
ADDRESS:25371 MAXIMUSTELEPHONE:
(949) 472-4636
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Hermelinda Perez, AdministratorTIME COMPLETED:
05:00 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after stating the purpose of the visit. Administrator Hermelinda Perez was notified by telephone and arrived later to assist.

During the inspection, LPA and facility staff conducted a tour of the physical plant and observed the following: The facility is a two-story home. The second floor is restricted for use by the licensee with no resident dwellings. The ground floor is shown to have one private and two shared resident bedrooms and two bathrooms in addition to the common living areas. All resident bedrooms have the required furnishings. LPA observed all beds have linens and blankets. The backyard has a shaded area and the routes of egress are free of clutter and obstructions. There are currently five residents in care at the facility, two of which are receiving hospice care. Residents are observed to be clean and appear well taken care of. Bathrooms faucets and toilets were operational. Water temperature was verified to be within acceptable range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required. Combined smoke and carbon monoxide detectors tested operational. Fire extinguisher present is observed to be fully charged. Medication, sharp items and cleaning supplies were confirmed to be inaccessible throughout the physical plant. The medication central storage was also observed to be secure and reviewed for accuracy during the visit. LPA reviewed five resident files and three staff files. One staff member on duty was interviewed during the visit in addition to two residents.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. One Technical Violation Advisory Note was provided to the licensee. An exit interview was conducted, and a copy of this report was 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: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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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