306004475-9-25-2024-22-AS-KSGH-D9FVRP-20240925164016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004475
Report Date: 09/25/2024
Date Signed: 09/25/2024 04:41:12 PM

Document Has Been Signed on 09/25/2024 04:41 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:	AEGEAN HILLS SENIOR LIVING		FACILITY NUMBER:	306004475
ADMINISTRATOR:	MENDOZA, ADRIANA		FACILITY TYPE:	740
ADDRESS:	25622 MAXIMUS		TELEPHONE:	(949) 215-8980
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 5	DATE:	09/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Richard Mendoza, Administrator		TIME COMPLETED:	04:55 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 for the purpose of conducting the Required Annual Inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the reason of the visit. Administrator Richard Mendoza arrived later to assist with the visit. During the inspection, LPA and staff conducted a tour of the physical plant and observed the following: The facility is a one-story home with four private and one shared bedrooms in addition to a staff room. There are two bathrooms throughout the facility. All bathrooms are observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. LPA observed all beds have linen and blankets. Postural supports with corresponding orders are observed, however one bedroom is equipped with full length rails in spite of the resident not currently receiving hospice care. Type B citation issued. There are currently five residents admitted to the facility, none of which are receiving hospice care. Bathrooms faucets and toilets are operational. Water temperature was measured to be within acceptable temperature range. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Drills are conducted quarterly however they are not systematically documented. Consultation provided. 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 extinguishers present are fully charged and have been maintained in 2024. There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on both sides of the property. The routes of egress are free of obstructions. There are no bodies of water on the premises. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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: AEGEAN HILLS SENIOR LIVING	FACILITY NUMBER: 306004475
	VISIT DATE: 09/25/2024

NARRATIVE

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CONTINUED FROM FORM LIC809
Medication, cleaning products and sharp items are confirmed to be inaccessible throughout the physical plant. 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. Medication is observed to be prepared two to three days ahead of dispensation. Consultation provided on pre-pouring medication as a Technical Violation Advisory Note.

LPA reviewed five resident files and 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 records are maintained at an administrative location off-site. Training and CPR stated to be up to date. Physician reports need to be updated for three residents with a diagnosis of dementia. Type B citation issued.

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 Advisory Notes issued along with consultations provided to the licensee.

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: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/25/2024 04:41 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: AEGEAN HILLS SENIOR LIVING	FACILITY NUMBER: 306004475
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(5)(B)

Postural Supports

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as one bedroom is observed to be equipped with a prescribed full-length rail. Resident is not on hospice at this time. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/04/2024
	Plan of Correction
1 2 3 4	Licensee will replace the full-length rail with a half-rail as soon as possible and provide LPA with proof of the replacement before the plan of corrections due date.

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the licensee did not comply with the section cited above three out of five physician report have been established over a year ago for residents with dementia diagnosis on file. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2024
	Plan of Correction
1 2 3 4	Licensee to obtain updated medical assessments. Documentation to be provided to LPA before the plan of corrections 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 Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: (714) 497-8754
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

LIC809 (FAS) - (06/04)

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