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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004793
Report Date: 08/20/2024
Date Signed: 08/20/2024 04:16:39 PM


Document Has Been Signed on 08/20/2024 04:16 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SEASONS AT LAGUNA - 2FACILITY NUMBER:
306004793
ADMINISTRATOR:MARICEL GUIDILONDOFACILITY TYPE:
740
ADDRESS:28961 PASEO DE OCASOTELEPHONE:
(949) 340-6688
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 6DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:Jennifer Floresca, Fez JonTIME COMPLETED:
04:52 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted by staff and granted entry. LPA met with Administrator Fez Jon and explained the reason for the visit. The Administrator's certificate expires on April 7, 2026. Facility is a one story home with 6 bedrooms, 5 bathrooms, living room, kitchen, dining room, 2 staff rooms and a 2 car garage. Facility is licensed for 6 non-ambulatory residents of which 6 can be bed ridden and a hospice waiver for 3. There is a screened fireplace in bedroom 1. LPA observed the See Something, Say Something Poster (PUB 475) posted in the main entry way of the facility. LPA and staff toured the facility. LPA observed all resident bedrooms had the required furnishings and bed linens. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Knives are kept locked in a kitchen drawer. LPA observed the 4 burner gas stove lights unassisted. LPA observed the fire extinguisher in the kitchen is fully charged. LPA observed medications are kept locked in the hall closet. All 5 bathrooms are clean and operational. Hot water measured 108.0 to 110.0 degrees Fahrenheit in all 5 bathrooms. LPA observed a clean supply of linens and towels in the hall closet. LPA and staff toured the garage. The garage is kept locked. Cleaning supplies and emergency food and water are stored in the garage. LPA and staff toured the backyard. There is a covered patio that provides shaded seating. No bodies of water observed. The exit gates on each side of the house are operational. Smoke detectors/carbon monoxide detectors tested operational. Facility has a tablet that can connect to the internet for resident use. The last facility fire drill took place June 1, 2024. Administrator Fez Jon left the facility during the visit due to an previously scheduled appointment. LPA reviewed 2 staff files. LPA observed Staff 1 (S1) did not have the required 20 hours of annual training. Both staff files reviewed had current CPR training. LPA reviewed 6 resident files, no discrepancies observed. LPA reviewed 6 resident medications, no discrepancies observed. LPA inspected the first aid kit. The first aid kit has all required elements. Deficiencies are being cited per Title 22 Division 6 of the California Code or Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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Document Has Been Signed on 08/20/2024 04:16 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: SEASONS AT LAGUNA - 2
FACILITY NUMBER: 306004793

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
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
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 Staff members, Staff 1 did not have the required 20 hours of training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee agrees to have Staff 1 complete an additional 3 hours of training to meet the 20 hour annual requirement. Licensee to forward proof to LPA by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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