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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004793
Report Date: 08/16/2022
Date Signed: 08/16/2022 12:31:34 PM


Document Has Been Signed on 08/16/2022 12:31 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:SEASONS AT LAGUNA - 2FACILITY NUMBER:
306004793
ADMINISTRATOR:FEZ JONFACILITY TYPE:
740
ADDRESS:28961 PASEO DE OCASOTELEPHONE:
(949) 340-6688
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 6DATE:
08/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Maricel Guibilondo, Jennifer FlorescaTIME COMPLETED:
12:45 PM
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On 08/16/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Seasons at Laguna-2. The purpose of today's visit was to conduct a Required 1 Year visit focusing primarily on the Infection Control. At 10:43am, LPA Cho was allowed entry into the facility and met with Caregiver Jennifer Floresca after completing the Coronavirus 2019 (COVID-19) screening procedure. Caregiver Hannalou Pichon was also present at this time. Administrator (Admin) Maricel Guibilondo arrived at the facility around 11:30am. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The Complaint Poster (PUB475) was observed in the size of 8.5"x11." Admin and Caregiver Floresca were informed to obtain the poster in the required sizing of 20"x26." The facility is licensed for six non-ambulatory residents and has a hospice waiver for three. There are currently six residents living in the facility of which three are receiving hospice care. The Administrator's Certificate for Maricel Guibilondo expires on 11/02/2023.

At 11:11am, LPA Cho conducted a tour of the physical plant along with Admin and Caregiver Floresca. The single story home consists of five resident bedrooms with four resident bathrooms. There is one staff bedroom and one staff bathroom. The facility also has a living room, dining area, kitchen, office area, and an attached two car garage. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew, and a non-skid mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. LPA observed the hand washing signs in all bathrooms. LPA Cho tested the hot water temperature in the resident bathrooms and the temperatures measured at 112.3 degrees Fahrenheit in the Bathroom #1, 111.2 degrees Fahrenheit in Bathroom #2, and 110.3 degrees Fahrenheit in Bathrooms #3 and #4.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2022
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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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: SEASONS AT LAGUNA - 2
FACILITY NUMBER: 306004793
VISIT DATE: 08/16/2022
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LPA Cho inspected the kitchen along with Admin and Caregiver Floresca. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. The auditory alarms throughout the facility were in operating condition.

LPA Ch toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and the exit gates were self-closing and self-latching. There were no security bars or weapons on the premises.

LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility does have back-up emergency food and water supply. The First Aid Kit met all the required components including the first aid manual, and the facility had sufficient PPEs.

No resident or staff files were reviewed at the time of this visit. LPA reviewed the COVID-19 mitigation plan of the facility as well as SB 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. The facility does have an existing internet service and provides a smart phone upon request. In addition, LPA discussed the importance of staying in compliance with the latest guidelines which includes the Infection Control Plan (LIC9282).

LPA provided the following guidance to Administrator Guibilondo: to enlarge the Complaint Poster (PUB475) to the required sizing of 20"x26," to submit the Infection Control Plan (LIC9282) by August 31, 2022, and to staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102) were issued during the visit. An exit interview was conducted with Administrator Maricel Guibilondo, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC809 (FAS) - (06/04)
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