306004782-12-16-2024-22-AS-KLYN-DBZVNE-20241216153500

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004782
Report Date: 12/16/2024
Date Signed: 12/16/2024 03:35:21 PM

Document Has Been Signed on 12/16/2024 03:35 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:	PLEASANTVIEW HOME, THE		FACILITY NUMBER:	306004782
ADMINISTRATOR/ DIRECTOR:	PATRICK JOHN BESINGA		FACILITY TYPE:	740
ADDRESS:	28911 LA LITA LANE		TELEPHONE:	(949) 364-1933
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92692
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:40 PM
MET WITH:	Mariza Oliva		TIME VISIT/ INSPECTION COMPLETED:	04:00 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 Analysts (LPAs) Kimberly Lyman and Fred Arias conducted an unannounced visit to The Pleasantview Home. The purpose of today’s visit was to conduct the annual required inspection. LPAs were allowed entry into the home and met with Administrator Mariza Oliva and explained the reason for the visit. Facility is licensed for 5 non-ambulatory residents and one bedridden. Facility has an approved hospice waiver for 5 residents and the home currently has 5 residents, with 1 resident on hospice. Administrator Mariza Oliva has an administrator certificate expiring on 05/04/2026. LPAs along with Administrator toured the facility at 12:55 PM. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 5 resident bedrooms, living room, dining room, and kitchen as well as 3 restrooms. Upon starting the tour, LPAs tested smoke detectors and carbon monoxide detector. The carbon monoxide detector is inoperable and four out of six smoke detectors are either missing or inoperable. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. At 1:10 PM, LPAs observed unsecured medications in a storage area. Resident bathrooms were checked.. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105 degrees F and 111.9 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPAs observed sharps as well as cleaning supplies locked under the sink. Kitchen appliances were operational during today's visit. Fire extinguishers were fully charged. LPAs reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 10/02/2024. LPAs observed ample emergency food and water. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. There is ample shaded seating for residents. Continued on LIC 809-C dated 12/16-2024

Alisa Ortiz	TELEPHONE: (714) 703-2855
Kimberly Lyman	TELEPHONE: (714) 795-1497
	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: PLEASANTVIEW HOME, THE	FACILITY NUMBER: 306004782
	VISIT DATE: 12/16/2024

NARRATIVE

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First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of music, exercise and games. Exit gate is unlocked and operational. At 1:30 PM, LPAs reviewed five resident files and three staff files. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including medical assessment/ TB, criminal record clearance and proof of CPR training. Three out of three staff files do not contain proof of annual required training hours. LPAs reviewed medication storage and administration. Medications are stored in a locked closet. Medications are being administered per physician order.

Licensee has been asked to provide an updated LIC 500 (Personnel report), LIC 610 (Emergency Disaster Plan), and LIC 308 (Designation of Facility Responsibility) by 12/30/2024.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/16/2024 03:35 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: PLEASANTVIEW HOME, THE	FACILITY NUMBER: 306004782
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Regulations

Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections. 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 in one out of one carbon monoxide detectors which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	Licensee to repair/ replace carbon monoxide detector and forward proof to LPA by POC due date.

Section Cited

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or 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 one out of one staff that is not associated to the facility which poses an immediate health, safety or personal rights risk to persons in care. CIVIL PENALTY ASSESSED
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	Licensee to submit a transfer request/ Guardian system to transfer staff 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.

Alisa Ortiz	TELEPHONE: (714) 703-2855
Kimberly Lyman	TELEPHONE: (714) 795-1497
	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 12/16/2024 03:35 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: PLEASANTVIEW HOME, THE	FACILITY NUMBER: 306004782
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. 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 three staff which do not have required annual training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2024
	Plan of Correction
1 2 3 4	Licensee to provide staff training 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.

Alisa Ortiz	TELEPHONE: (714) 703-2855
Kimberly Lyman	TELEPHONE: (714) 795-1497
	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 12/16/2024 03:35 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: PLEASANTVIEW HOME, THE	FACILITY NUMBER: 306004782
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. 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 in four out of six smoke detectors that are either missing or inoperable which poses an immediate health, safety or personal rights risk to persons in care. CIVIL PENALTY ASSESSED
	POC Due Date: 12/17/2024
	Plan of Correction
1 2 3 4	Licensee to repair/ replace smoke detectors and forward proof to LPA.

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.

Alisa Ortiz	TELEPHONE: (714) 703-2855
Kimberly Lyman	TELEPHONE: (714) 795-1497
	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC809 (FAS) - (06/04)

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