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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004186
Report Date: 12/05/2023
Date Signed: 12/05/2023 03:25:19 PM


Document Has Been Signed on 12/05/2023 03:25 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:HORIZON LEGACY ELDERLY CARE HOMEFACILITY NUMBER:
306004186
ADMINISTRATOR:PEDROZA, JOHNFACILITY TYPE:
740
ADDRESS:25351 DIANA CIRCLETELEPHONE:
(949) 859-1217
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
12/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Pablo Pedroza, AdministratorTIME COMPLETED:
03:45 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a case management visit regarding information discovered during the investigation into complaint control # 22-AS-20230519142410.

During the complaint investigation mentioned above, it was discovered Resident R1’s pressure injuries, assessed at a stage 2 upon admission on March 4, 2023 had been assessed to have degraded to a stage 3 level on May 5, 2023 and remained at that level until R1 was hospitalized for an unrelated condition on May 17, 2023. Per Title 22 regulations, pressure injuries at stages 3 and 4 are defined as Prohibited Health Conditions, meaning that R1 should not have been retained in a residential care facility for the elderly without a confirmed exception, for which licensee did not apply prior to R1 being transferred to the hospital.

As a result of today’s Case Management visit, a Technical Violation Advisory note will be issued.

An exit interview was conducted and a copy of this report along with Technical Violation Advisory Note form LIC9102 were provided
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
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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