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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004397
Report Date: 02/28/2022
Date Signed: 02/28/2022 05:01:04 PM


Document Has Been Signed on 02/28/2022 05:01 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:HORIZON PRIMAVERA SENIOR LIVINGFACILITY NUMBER:
306004397
ADMINISTRATOR:PEDROZA, JOHNFACILITY TYPE:
740
ADDRESS:25341 DIANA CIRCLETELEPHONE:
(949) 859-8391
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
02/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:25 PM
MET WITH:Flor Pedroza, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of conducting a required annual inspection visit. LPA arrived at facility, explained the purpose of the visit and was greeted by staff and granted entry by Administrator Flor Pedroza.

At approximately 4:30pm, LPA accompanied by Administrator began the tour of the facility. There are currently five (5) residents in care, none of which are on hospice. The residents are observed relaxing in the common areas or in their bedrooms and appear well taken care of. Facility appears to be clean, sanitary and free of odors in all areas inspected. LPA observed a check-in station right at the entrance of the facility where visitors temperature checks are being documented. LPA observed the facility has COVID-19 Precautions posters, all required department postings and hand washing signs are posted throughout. LPA observed a sufficient supply of food and water. Facility has an adequate supply of PPE stored in the attached garage. LPA toured the outside of the facility and observed outdoor seating for the residents' enjoyment. Outdoor space is free of debris and well-maintained with self-latching gates that can easily be opened on both sides of the house. However a shed containing gardening equipment and toxics is currently unlocked in the service area of the yard. Each bedroom is observed to have all required components and bathrooms are equipped with grab bars and slip mats.
The facility has completed and submitted their LIC808 Mitigation Plan which has been approved by LPA Albert Marin on 07/08/2021.

Based on the observations made during today’s visit, deficiencies are being cited today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with facility representative and a copy of this report and appeals rights was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
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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Document Has Been Signed on 02/28/2022 05:01 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: HORIZON PRIMAVERA SENIOR LIVING
FACILITY NUMBER: 306004397

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia. The following items shall be made inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by: The shed in the garden contains gardening tools as well as phytosanitary products and cannot be kept locked and secure from the reach of the individuals in care.
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one instance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/04/2022
Plan of Correction
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The licensee will secure the garden shed and provide LPA with evidence before Friday 03/04/2022.
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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2022
LIC809 (FAS) - (06/04)
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