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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004186
Report Date: 04/30/2024
Date Signed: 04/30/2024 05:03:42 PM


Document Has Been Signed on 04/30/2024 05:03 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:
04/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:John Mendoza, Licensee
Celfa Aronne, Prospective licensee & Administrator		TIME COMPLETED:
05:00 PM
NARRATIVE
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On this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Rose-Mary Ruppert made an unannounced visit to the facility for the purpose of conducting the Required Annual Inspection. LPAs were greeted and granted entry by facility caregiving staff after introducing themselves and stating the reason of the visit. Administrator Celfa Aronne was notified of the visit 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 one-story home with four private resident bedrooms, one shared bedroom, one staff bedroom and two shared bathrooms. All resident bedrooms had the required furnishings. LPAs observed all beds had linens and blankets and an adequate additional supply is present. 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, three 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. LPAs observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Combined smoke and carbon monoxide detectors tested operational. Fire extinguisher present is observed to be fully charged with up-to-date maintenance. 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. LPAs reviewed five resident files and four staff files. The two staff members on duty were interviewed along with four residents.

Based on the observations made during today’s inspection, two type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Three Technical Violation Advisory Notes were also provided to the licensee. An exit interview was conducted, and a copy of this report along with appeal rights 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: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 04/30/2024 05:03 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: HORIZON LEGACY ELDERLY CARE HOME
FACILITY NUMBER: 306004186

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff records reviewed during the facility visit, the licensee did not comply with the section cited above for two staff members who are not associated to the licensed location in Guardian. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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Staff association for both missing staff members will be submitted in Guardian by licensee. Proof of association to be provided to LPA before the plan of corrections due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review of the facility's Emergency and Disaster Plan, the licensee did not comply with the section cited above as no documentation of recent fire and emergency drills could be provided during the facility visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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Proof of completion for a current fire and emergency drill and a plan for the next few quarters are to be provided to LPA before the plan of correction due date.
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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024
LIC809 (FAS) - (06/04)
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