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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004588
Report Date: 07/07/2022
Date Signed: 07/07/2022 02:19:21 PM


Document Has Been Signed on 07/07/2022 02:19 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:
07/07/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Esther ReyTIME COMPLETED:
02:40 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Celine DePero made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 06/28/2022. LPAs were greeted and granted entry into the facility by Administrator Esther Rey and explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Centrally Stored Medications has been cleared. Licensee secured noted items. Licensee has complied with the terms of the POC.

.*Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to Inaccessible Items (Care of Persons with Dementia) has NOT been cleared. Licensee did not secure items. LPAs observed unsecured vitamins, Windex, and disinfectant spray. Licensee has NOT complied with the terms of the POC. CIVIL PENALTY ISSUED.


Administrator to provide an updated LIC 500 to LPA by 07/14/2022.





Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
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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