<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005351
Report Date: 06/21/2022
Date Signed: 06/21/2022 02:50:22 PM


Document Has Been Signed on 06/21/2022 02:50 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:LA VIDA AT MISSION VIEJOFACILITY NUMBER:
306005351
ADMINISTRATOR:JUSTINE ORTIZFACILITY TYPE:
740
ADDRESS:27783 CENTER DRIVETELEPHONE:
(949) 364-6210
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:150CENSUS: 97DATE:
06/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Justine OrtizTIME COMPLETED:
03:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced case management visit to follow up on incident reports received by Community Care Licensing. LPA was greeted and granted entry into the facility by Executive Director Justine Ortiz and explained the reason for the visit.

Incident report dated 06/09/2022 indicated Resident 1 (R1) eloped out of the memory care unit and was found about one mile away by facility staff. Facility investigation revealed the alarm went off at rear gate at approximately 7:40 PM. Staff responded to the alarm and began a head count. It was noted R1 was absent and staff started looking for the resident. Facility contacted the authorities as well. Camera footage indicated the resident went into the courtyard and then out the gate. It is presumed the resident went through the field adjacent to the facility and up onto the road. Resident was discovered by staff by a shopping center and returned to the facility with no adverse effects. Resident was put on half hour checks and family and physician notified. Per physician report dated 04/29/2022, R1 has a diagnosis of Dementia and a history of wandering. LPA spoke with R1 during the visit. R1 appeared happy and well taken care of.

Incident report dated 05/31/2022 indicated R2 was found on the floor by staff in the resident's restroom around 12:55 AM. R2 was observed to have a skin tear and became somewhat incoherent. 911 was called and paramedics responded. R2 was transported to Mission hospital and diagnosed with a fractured right hip. R2 had surgery and was transported to a skilled nursing facility. Per physician report dated 05/22/2020, R2 is diagnosed with Mild Cognitive Impairment. Resident was on Hospice due to Senile Degeneration of the brain. Per facility, resident was on two hour checks, had bed rails and a pendant for assistance.

Based on the observations and interviews made, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided with Executive Director.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
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 2


Document Has Been Signed on 06/21/2022 02:50 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: LA VIDA AT MISSION VIEJO
FACILITY NUMBER: 306005351

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2022
Section Cited

1
2
3
4
5
6
7
Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
8
9
10
11
12
13
14
Based on observation and interview, Licensee failed to ensure care and supervision was provided to R1. R1 eloped out of the facility and was found approximately a mile away from the facility. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2