<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004588
Report Date: 06/28/2022
Date Signed: 06/28/2022 03:02:57 PM


Document Has Been Signed on 06/28/2022 03:02 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:CARING SISTERS HOME AND GARDEN @ LAKE FORESTFACILITY NUMBER:
306004588
ADMINISTRATOR:ESTHER CORTEZ REYFACILITY TYPE:
740
ADDRESS:23191 LA VACA STREETTELEPHONE:
(949) 613-1114
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 5DATE:
06/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Esther ReyTIME COMPLETED:
02:19 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
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Licensee/ Administrator Esther Rey and explained the reason for the visit. Administrator Rey has a current administrator certificate expiring on 02/27/2024.
At 11:31 AM, LPA toured the facility with Administrator Rey. Facility has 5 residents in care during today's visit with two on hospice. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. At 11:35 AM, LPA toured the unlocked garage and observed unsecured cleaners and laundry supplies. LPA observed unsecured cleaning supplies in the adjacent restroom. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Rooms are single and double occupancy. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet. Facility takes resident and staff temperatures daily. LPA observed the first aid kit has all required items. At 11:45 AM, LPA observed the medication closet is unlocked and medications are accessible to residents in care. There are unsecured vitamins and cleaning supplies/ disinfectants in the kitchen as well as unsecured medication in the refrigerator. Sharps are unlocked under the kitchen counter. LPA observed an ample supply of emergency food and water as well as PPE. Smoke detectors tested operational during today's visit. LPA toured the outside grounds and observed the shaded outside visitation area. Facility has unsecured toxins in the outside visitation area as well as unsecured sharps. Exit gate is unlocked and self latching. Residents participate in activities such as puzzles, exercise, and drives in the community. LPA reviewed all resident files and three out of five residents with Dementia have outdated physician reports. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. All residents and staff are vaccinated for Covid-19.
LPA consulted with Administrator regarding the importance of hand washing signs in all facility restrooms as well as ensuring the emergency disaster plan is posted in the facility. Additionally, LPA consulted with Administrator regarding visitation guidelines.
CONTINUED ON LIC 809C DATED 06/28/2022.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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 4


Document Has Been Signed on 06/28/2022 03:02 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: CARING SISTERS HOME AND GARDEN @ LAKE FOREST
FACILITY NUMBER: 306004588

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
The following shall be stored 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:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed unsecured cleaning supplies, disinfectant sprays, pest spray, over the counter medications and vitamins in multiple areas throughout the facility including garage, restrooms, kitchen and outside visitation area (photos). This poses an immediate health and safety risk to persons in care.
POC Due Date: 06/29/2022
Plan of Correction
1
2
3
4
Licensee to secure all noted items and forward proof to LPA by POC due date.
Type A
Section Cited
CCR
87465(h)(2)
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.


This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above. LPA observed unsecured medication in the refrigerator as well as the unlocked medication cabinet (photos) which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/29/2022
Plan of Correction
1
2
3
4
Licensee to secure noted medications and forward proof to LPA by POC 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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 06/28/2022 03:02 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: CARING SISTERS HOME AND GARDEN @ LAKE FOREST
FACILITY NUMBER: 306004588

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(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 record review, the licensee did not comply with the section cited above in three out of five medical assessments. This poses a potential health and safety risk to persons in care.
POC Due Date: 07/12/2022
Plan of Correction
1
2
3
4
Licensee to obtain updated physician reports for residents #2, 4 and 5 and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4

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) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: CARING SISTERS HOME AND GARDEN @ LAKE FOREST
FACILITY NUMBER: 306004588
VISIT DATE: 06/28/2022
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
26
27
28
29
30
31
32
Based on the observations made during today's visit, Deficiencies are being cited under California Code of Regulations, Title 22, Division 6, Chapter 8.
Exit interview conducted with Administrator Rey and a copy of this report along with the appeal rights and LIC 811 were provided at the time of this visit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4