306003838-2-5-2025-22-AS-KSGH-DDLRFW-20250205115947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003838
Report Date: 02/05/2025
Date Signed: 02/05/2025 12:00:21 PM

Document Has Been Signed on 02/05/2025 12:00 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 HOME		FACILITY NUMBER:	306003838
ADMINISTRATOR/ DIRECTOR:	HERMELINDA/MIGUEL PEREZ		FACILITY TYPE:	740
ADDRESS:	25371 MAXIMUS		TELEPHONE:	(949) 472-4636
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	02/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:12 AM
MET WITH:	Hermelinda Perez, administrator		TIME VISIT/ INSPECTION COMPLETED:	12:15 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	On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility to conduct the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator Hermelinda Perez was notified of the visit via telephone and arrived shortly afterwards to assist with the visit. There are currently five residents in care, three of which are currently receiving hospice care after one resident alternated from her admission into palliative care. LPA observed residents relaxing in their respective bedrooms or in the facility's common living areas. LPA accompanied by facility staff toured the physical plant. The facility is a two-story house with an attached garage. The second level is for use by the licensee and their family exclusively, with all family members over 18 shown to be background cleared. The facility has one private bedroom and two shared rooms . There are two full bathrooms throughout the facility, one designated for use by residents and the other one for staff, visitors and third-party providers. Bedrooms appeared clean and sanitary. Two beds are equipped with full rails and one bed with half rails. Physician orders and hospice plans of care for all postural supports in use reviewed. LPA observed all the resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Bathroom are equipped with grab bars and slip mats. Hot water temperature measured at 113.2F in the bathroom used by residents. LPA observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items are stored in a secure drawer. Fire extinguisher is charged and mounted, with up-to-date maintenance documented on an attached receipt. LPA tested the smoke and carbon monoxide detectors which were found to be operational. The centrally stored medication is located in a secure closet located in the dining area. The attached garage is inaccessible to residents and is used for storage and laundry, with an additional refrigerator/freezer present. Cleaning supplies are stored securely in the garage. CONTINUED ON FORM LIC809-C

Sheila Santos	TELEPHONE: (714) 334-2062
Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
	DATE: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MEISON LA PAZ IV ELDERLY CARE HOME	FACILITY NUMBER: 306003838
	VISIT DATE: 02/05/2025

NARRATIVE

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CONTINUED FROM FORM LIC809
LPA and facility staff toured the outside of the facility. LPA observed an shaded outdoor seating area with furniture for resident use. The perimeter gate on one side of the property is self-latching and can easily be opened in an evacuation. There is a fully fenced swimming pool on the premises which is kept inaccessible to residents.

LPA reviewed five resident records which included all necessary components. LPA reviewed resident medication records and prescription orders with no discrepancies observed. One resident interview conducted during the visit. There are no bedridden residents present on the premises. LPA reviewed two staff records which were found to be complete with the exception of the most recent annual training which was verified to have been conducted but was not documented by the administrator. Consultation provided. CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately. Licensee does not hold a current liability insurance at the time of the visit after encountering issues during their renewal. Licensee states a new insurance coverage is in the process of being acquired within the next two weeks. Type B citation issued.

Based on the observations made during today’s visit, one type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations and three consultations are provided. An exit interview was conducted and a copy of this report along with appeal rights 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: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/05/2025 12:00 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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MEISON LA PAZ IV ELDERLY CARE HOME	FACILITY NUMBER: 306003838
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above as there were issues with renewing the previous liability insurance coverage resulting in no active coverage at the time of the visit. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2025
	Plan of Correction
1 2 3 4	Licensee stated a new insurance contract was in progress and could be provided when signed, which should be within ten days of the present visit. Documentation will be provided to licensing staff upon acquisition of adequate coverage.

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.

Sheila Santos	TELEPHONE: (714) 334-2062
Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
	DATE: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

LIC809 (FAS) - (06/04)

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