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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005155
Report Date: 01/16/2025
Date Signed: 01/16/2025 12:55:20 PM

Document Has Been Signed on 01/16/2025 12:55 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/
DIRECTOR:		RAMJO MASANQUEFACILITY TYPE:
740
ADDRESS:24052 PLANT AVENUETELEPHONE:
(949) 393-3120
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:54 AM
MET WITH:Rommel Divina GraciaTIME VISIT/
INSPECTION COMPLETED:
01:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by Administrator (AD) Milany Mora and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents, with a hospice waiver for five and bed-ridden for all. Currently there are six residents, of which two are on hospice during today's visit.

At around 9:18 AM, LPA Tea reviewed six resident files and one staff file. There were discrepancies noted in the review of resident and staff files. Administrator certificate expires on December 02, 2025. Last facility disaster drill was conducted on December 1, 2024.



LPA Tea along with caregiver toured the facility around 10:00 AM. LPA toured the physical plant, checked food service, and the first aid kit. The facility is a single-story home that consists of 6 resident bedrooms, 2 caregiver rooms, 4 bathrooms, living room, dining room, kitchen, and attached garage. LPA observed smoke detectors/carbon monoxide in common areas and bedrooms, and they are operational. Resident bedrooms had the required furniture, 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 and shower was free of mold/mildew. Water temperature measured between 116.6 degrees F and 114 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including bandages, dressings, tweezers, thermometer, and scissors. Kitchen was inspected. One of the burners of the kitchen stove was not working. LPA explained that it needs to be fixed or replaced. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. LPA also observed toxin substances to be locked and inaccessible to clients in care locked and secured in the garage. The fire extinguishers throughout the facility were fully charged. LPA toured the outside grounds and there is ample seating with shade and two exit gates on both sides of the facility are self-latching and operational. LPA observed emergency supplies, food and water supply in the garage.

Annual Inspection continued on LIC809-C
Alisa OrtizTELEPHONE: (714) 287-4084
Michael TeaTELEPHONE: 714-703-2840
DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 01/16/2025 12:55 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: 01/16/2025
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
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Based on LPA's review of facility records one staff does not have documentation of current year staff training. This could pose a potential health and safety risk to residents in care.
POC Due Date: 01/30/2025
Plan of Correction
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Adrministrator/licensee will provide proof of training for staff by POC due date.
Section Cited
Exceptions for Health Conditions
(b) Written requests shall include, but are not limited to, the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of resident records, residents with dementia did not have updated medical reports. This could pose as a potential health and safety risk to residents in care.
POC Due Date: 02/06/2025
Plan of Correction
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Licensee/administrator will obtain updated medical reports for residents with dementia and provide copies or 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 OrtizTELEPHONE: (714) 287-4084
Michael TeaTELEPHONE: 714-703-2840

DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2025 12:55 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: 01/16/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Maintenance and Operations 87303 (a) ... The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation during facility tour, one stove burner was not working.
POC Due Date: 01/30/2025
Plan of Correction
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Licensee/administrator needs to repair or replace stove and provide proof to LPA on 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.
Alisa OrtizTELEPHONE: (714) 287-4084
Michael TeaTELEPHONE: 714-703-2840

DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025

LIC809 (FAS) - (06/04)
Page: 4 of 6
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: 01/16/2025
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 Facility provides activities based on resident interests. The residents watch play trivia and answer brain teaser questions, exercises, listen to music and watch television. At the time of annual visit, residents were seen reading and watching television and having lunch later on during the visit.

LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the kitchen. Medications are being administered per physician order but not properly documented. LPAs interviewed residents regarding their quality of care and spoke to staff present regarding care provided.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator Milany Mora and a copy of these reports were given to the facility along with a copy of the LIC 858; 859;809-D, 9102 and Appeal Rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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