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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005155
Report Date: 06/06/2024
Date Signed: 06/06/2024 04:59:40 PM


Document Has Been Signed on 06/06/2024 04:59 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-4FACILITY NUMBER:
306005155
ADMINISTRATOR:RAMJO MASANQUEFACILITY TYPE:
740
ADDRESS:24052 PLANT AVENUETELEPHONE:
(949) 393-3120
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
06/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Milany Mora- AdministratorTIME COMPLETED:
05:00 PM
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Licensing Program Analysts (LPAs) Jessica Cho and Michael Tea conducted an unannounced Required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs Cho and Tea met with Caregiver Rommel DivinaGracia and stated the purpose of the visit followed by Administrator Milany Mora.

The facility is licensed to operate for six (6) non-ambulatory and maintains a hospice waiver of five (5). The facility is a single-story structure located in a residential neighborhood. LPAs toured the physical plant accompanied by Caregiver DivinaGracia at 2:15pm, and the following were observed:

LPAs toured the inside and facility appeared clean, organized, and in sanitary condition. There are a total of six (6) resident and two (2) staff bedrooms. The resident bedrooms were appropriately furnished and the bedding in the resident bedrooms were in good condition. Adequate lighting was provided and storage for personal belongings were observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. There are a total of four resident bathrooms which measured at 122.3, 120.3, 128.0, and 129.4 degrees Fahrenheit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharp objects were stored and inaccessible to the residents. The kitchen was inspected and facility maintains a two-day supply of perishables and seven-day supply of non-perishable food. Medications were centrally stored however the locking mechanisms for the medication cabinets were not working properly. The facility has two fire extinguishers that are charged and serviced on 09/19/2023. Auditory devices and smoke/carbon monoxide detectors were tested and operational. The facility conducted a Fire/Safety Drill on 06/01/2024. A working telephone (949) 393-3120 remains available. First Aid Kit contained all the necessary elements. The 'See Something Say Something' Poster (PUB475) was maintained at 8.5"x11" however did not meet the required size of 20"x26." LPA toured the outside grounds. The exit gates were self-closing and self-latching.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
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 06/06/2024 04:59 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-4

FACILITY NUMBER: 306005155

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87302(e)(2)
87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, two out of the four bathrooms measured at 128.0 and 129.4 degrees Fahrenheit which poses an immediate Health, Safety, and Personal Rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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The water was readjusted during the visit. Administrator to provide a water log measuring the water temperature weekly and provide the POC to LPA via email by POC due date.
Type A
Section Cited
CCR
87608(a)(3)
87608 Postural Supports (a) Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, facility did not maintain a written doctor's order for the half rail for one resident which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
POC Due Date: 06/07/2024
Plan of Correction
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Administrator stated that they will provide proof of the order for the half rail to LPA via email 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.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2024
LIC809 (FAS) - (06/04)
Page: 4 of 7


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-4
FACILITY NUMBER: 306005155
VISIT DATE: 06/06/2024
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LPAs conducted a file review of six residents' files and two personnel files which were in order. LPAs conducted two staff interviews and five resident interviews. Medications were audited for six residents and discrepancies were noted for Resident #1 (R1) and Resident #2 (R2) at the time of inspection.

The following items were advised: to repair the locking mechanism for the medication cabinets, obtain a PUB475 in the size of 20"x26," two out of the four bathrooms exceeded 120 degrees Fahrenheit, cameras observed in two resident bedrooms were removed during the visit, obtain a doctor's order for half rail for Resident #3 (R3), and to ensure medications prescribed by the doctor is accurately documented and updated as needed on the Centrally Stored Medication Destruction Record.

Based on the LPAs' observations, deficiencies are being cited today as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. Advisory Notes are also being issued.

An exit interview was conducted with Administrator Milany Mora, and a copy of this report along with the LIC809C, LIC809D, and the appeal rights were provided at the end of the visit.

SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2024
LIC809 (FAS) - (06/04)
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