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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004323
Report Date: 12/02/2024
Date Signed: 12/02/2024 05:23:43 PM

Document Has Been Signed on 12/02/2024 05:23 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 IFACILITY NUMBER:
306004323
ADMINISTRATOR/
DIRECTOR:		SAKVADOR DIAZ JRFACILITY TYPE:
740
ADDRESS:25421 MARINA CIRCLETELEPHONE:
(949) 859-5049
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Jennifer Perez, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On this day, Licensing Program Analysts (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 the caregiving staff after introducing himself and stating the purpose of the visit. Administrator Jennifer Perez was notified of the visit via telephone and arrived later to assist.

LPA accompanied by facility staff conducted a tour of the physical plant and observed the following: the facility is a two-story home with an attached garage. The upper level is only for use by licensee and their family and staff and is kept inaccessible to residents as verified during the visit. The facility's ground level has three shared bedrooms and two shared bathrooms. All bathrooms are observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. Bathrooms faucets and toilets are operational. Water temperature was measured at 130.5F and 135.2F in two bathrooms used for personal hygiene. Type B citation issued. LPA observed all beds have linen and blankets. There are half rails used for postural supports for three residents. Physician orders for two residents reviewed. A third resident received half rails ordered upon their admission, physician orders pending from skilled nursing.

There are currently six residents admitted to the facility with one of these residents currently admitted to rehabilitative care. Two residents are receiving hospice care out of a waiver capacity of two possible hospice residents. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. One occurrence of an evacuation drill has been conducted in 2024 for both shifts. Type B citation issued due to the quarterly frequency not being followed. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke and carbon monoxide detectors tested operational. Fire extinguisher present is fully charged and has been purchased in 2024 as demonstrated by the receipt on display.

CONTINUED ON FORM LIC809-C
Sheila SantosTELEPHONE: (714) 334-2062
Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/02/2024
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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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 I
FACILITY NUMBER: 306004323
VISIT DATE: 12/02/2024
NARRATIVE
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CONTINUED FROM FORM LIC809
There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on each side of the property. The route of egress on one side is free of obstructions, however there are construction materials partially blocking the path to the second gate. Technical Violation Advisory note issued.

Cleaning products are observed to placed in a lockable cabinet under the sink which staff state is locked at night. Consultation provided to remind licensee of the need to lock the cabinet when not attended directly by staff. The medication central storage was also observed to be secure and reviewed to be accurate and up to date with the resident's prescription orders.

LPA reviewed six resident files along with two staff files. Resident records include all necessary components. All staff members on the facility's roster are confirmed to be cleared and associated with this particular licensed location. Training verified to be up to date. CPR stated to have been conducted. Proof of training to be sent to LPA as soon as possible. Health screenings are on file for both staff members.

Proof of liability insurance coverage could not be provided. Licensee states that finding an insurance company to renew their previous contract has been challenging. Type B citation issued.

Based on the observations made during today’s inspection, three deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations and four Advisory Notes issued.

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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 12/02/2024 05:23 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 I
FACILITY NUMBER: 306004323

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
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
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Based on records review and administrator interview, the licensee did not comply with the section cited above as the liability insurance coverage is stated to have lapsed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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Licensee was advised by their insurance company to proceed to a change of ownership for insurance to be provided again. An application to that extent will be submitted to the Centralized Application Bureau.
Section Cited
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as two faucets were observed to deliver water above 120F during the visit which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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The water heater will be adjusted down and proof of adequate temperature will be provided to LPA.
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 SantosTELEPHONE: (714) 334-2062
Kevin Saborit-GuaschTELEPHONE: (714) 497-8754

DATE: 12/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2024

LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 12/02/2024 05:23 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 I
FACILITY NUMBER: 306004323

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/02/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
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 staff interview and records reviewed, the licensee did not comply with the section cited above as only one drill for two shifts was conducted in 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/02/2025
Plan of Correction
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Licensee will conduct one additional drill in 2024 and schedule quarterly drills for 2025. Documentation to be provided to LPA.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 SantosTELEPHONE: (714) 334-2062
Kevin Saborit-GuaschTELEPHONE: (714) 497-8754

DATE: 12/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/02/2024

LIC809 (FAS) - (06/04)
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