306005349-4-25-2022-22-AS-RMAZ-CDTSN8-20220425140106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005349
Report Date: 04/25/2022
Date Signed: 04/25/2022 02:01:09 PM

Document Has Been Signed on 04/25/2022 02:01 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:	LAS PALMAS		FACILITY NUMBER:	306005349
ADMINISTRATOR:	MONICA CASTILLO		FACILITY TYPE:	740
ADDRESS:	24962 CALLE ARAGON		TELEPHONE:	(949) 586-3393
CITY:	LAGUNA WOODS	STATE: CA	ZIP CODE:	92637
CAPACITY:	220	CENSUS: 139	DATE:	04/25/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Miriam Perez, Regional Nurse		TIME COMPLETED:	02:30 PM

NARRATIVE

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This unannounced case management visit is being conducted by Licensing Program Analyst (LPA) Ruth Martinez to follow up on an incident reported to Community Care Licensing. LPA arrived at facility was greeted by receptionist and granted entry. LPA met with Miriam Perez, Regional Nurse and explained the purpose of today’s visit. Incident was self reported on 02/08/2022 regarding R1’s incidents on 02/05/2022.

During today’s visit, LPA took a tour of the memory care unit, interviewed staff, completed a review of resident records and obtained copies of pertinent documents. R1 is diagnosed with dementia and was residing in the memory care unit of the facility. On 02/05/2022 while staff was doing routine checks for R1, R1 was found on the floor by the end of the bed. R1 had attempted to get out of bed when R1 had slipped down from bed. R1 complained of pain and 911 was immediately called. Facility staff made sure to have R1 in a comfortable position while paramedics arrived. In review of R1’s records it is indicated that R1 was on 24 times per day checks which would be checks hourly. R1 was a fall risk resident and therefore fall risk precaution was put in place. R1 was sent out to local hospital for evaluation and did not return to the community. R1 was referred to a skilled nursing facility for assistance with injury in question. R1 moved out of the community and moved to a smaller board and care that could provide one on one care. All responsible parties were notified.

LPA found that facility acted appropriately and in a timely manner to address the incident and all other immediate attention to injuries in question. LPA did not observe any immediate and/or safety risks in or out of the facility.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with facility representative and a copy of this report was provided and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022

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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