306004769-5-9-2023-22-AS-SSAS-CRXNW9-20230518104911

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306004769
Report Date: 05/09/2023
Date Signed: 05/09/2023 04:06:46 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2023 and conducted by Evaluator Patricia Velazquez

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20230503123003

FACILITY NAME:	SEASONS AT LAGUNA - 3		FACILITY NUMBER:	306004769
ADMINISTRATOR:	MARICEL GUIBILONDO		FACILITY TYPE:	740
ADDRESS:	26291 AVENIDA CALIDAD		TELEPHONE:	(949) 482-7412
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	05/09/2023
		UNANNOUNCED	TIME BEGAN:	02:13 PM
MET WITH:	Maricel Guibilondo - Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility staff are not providing activities for residents in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced initial 10 day complaint visit to initiate the investigation into the above allegation and delivered the findings of the investigation. LPA Velazquez was allowed entry into the facility and met with Administrator Maricel Guibilondo.

On today's visit LPA Velazquez conducted interviews with residents and staff. LPA Velazquez also reviewed and obtained copies of facility and resident records. Administrator Guibilondo agreed to provide LPA copies of the additional documents requested by May 12, 2023. LPA Velazquez also reviewed resident records which included Identification and Emergency Information, Physician's Reports, and Appraisal Needs and Services Plans. Two of the residents interviewed did not provide verbal responses and per Administrator Guibilondo are no longer verbal. Two residents were observed watching TV in the living area during the visit. Two of two individuals interviewed confirmed the facility does not provide activities to the residents. Per Administrator Guibilondo the facility has not provided activities to the residents since the onset of the COVID-19 Pandemic.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20230503123003

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SEASONS AT LAGUNA - 3	FACILITY NUMBER: 306004769
	VISIT DATE: 05/09/2023

NARRATIVE

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Per Administrator Guibilondo some residents do not want to participate in activities but this information is not documented in the resident files. Administrator Guibilondo further indicated they have been wanting to initiate providing activities for the residents once again.

Based on the observations of LPA Patricia Velazquez, interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the following allegation: Facility staff are not providing activities for residents in care is deemed SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is being cited on the attached LIC 9099D.

An exit interview was conducted with Administrator Maricel Guibilondo and a copy of this report along with the appeal rights and LIC 9098 were provided at the time of this visit. LPA Velazquez printed and provided Administrator Guibilondo a copy of Title 22 Regulation Section 87219 titled Planned Activities and Administrator acknowledged receiving a copy of said regulation at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20230503123003

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SEASONS AT LAGUNA - 3	FACILITY NUMBER: 306004769
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/15/2023 Section Cited CCR 87219(a)(1-6)	1 2 3 4 5 6 7	Planned Activities. Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall	1 2 3 4 5 6 7	Licensee to ensure it provides the residents in care with planned activities pursuant to Regulation and submit written proof to LPA by POC due date.
	8 9 10 11 12 13 14	include: (see 1-6). This requirement is not met as evidenced by: based on observation and interview the Licensee has not provided activities pursuant to regulation. This poses a potential risk to the health & safety of residents in care.	8 9 10 11 12 13 14	Licensee to provide a schedule of the planned activities to LPA by POC due date.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC9099 (FAS) - (06/04)

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