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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004520
Report Date: 04/02/2024
Date Signed: 04/02/2024 02:20:44 PM


Document Has Been Signed on 04/02/2024 02:20 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:MERIDIAN AT LAGUNA HILLSFACILITY NUMBER:
306004520
ADMINISTRATOR:TIERRE THORNTONFACILITY TYPE:
740
ADDRESS:24552 PASEO DE VALENCIA BLDG ATELEPHONE:
(949) 581-6111
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:150CENSUS: 77DATE:
04/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Karen Enciso, Continuous Improvement SpecialistTIME COMPLETED:
11:20 AM
NARRATIVE
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This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez to follow up on incident reported to Community Care Licensing. LPA arrived at facility greeted by receptionist and informed them of the visit. LPA met with Karen Enciso, Continuous Improvement Specialist and explained the nature of the visit.

Incident report for medication error on January 11, 2024 involving resident R1. Medtech staff (S1) mistakenly gave R1 a dose of medication that was intended for another resident. R1 was on status checks and there was no observations that R1 had adverse reaction to the medication. Power of attorney on record was notified and primary physicians was notified immediately. Facility did not receive a call from R1’s physician with indications after the incident. No adverse effects were noted with resident and incident in question. Facility continues to aggressively monitor medication for accuracy for all residents. Since incident facility has had no further medication errors on site.

Based on this inspection, deficiencies were observed at this time in the areas evaluated per Title 22 Division 6 of the California Code of Regulations. See LIC 809-D for deficiencies.

This report was reviewed with facility representative and a copy of this LIC809, LIC809-D report was provided and left at facility. Appeal rights reviewed, and a copy provided.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
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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Document Has Been Signed on 04/02/2024 02:20 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: MERIDIAN AT LAGUNA HILLS
FACILITY NUMBER: 306004520

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/16/2024
Section Cited
CCR
87465(a)(4)

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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(4) The licensee shall assist residents with self-administered medications
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Licensee stated they will provide additional training to all Medication Technicians and submit proof to LPA by POC due date.
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as needed. This requirement was not met as evidenced by: Based on interview and documents, the licensee did not ensure R1 received assistance with self-administered medications due to a medication error, which posed a potential health risk to persons in care.
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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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 04/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2024
LIC809 (FAS) - (06/04)
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