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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005351
Report Date: 12/14/2022
Date Signed: 12/14/2022 03:14:15 PM


Document Has Been Signed on 12/14/2022 03:14 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:FOUDIL MANADIFACILITY TYPE:
740
ADDRESS:27783 CENTER DRIVETELEPHONE:
(949) 364-6210
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:150CENSUS: 96DATE:
12/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Foudil ManadiTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Alvaro Ramirez made an unannounced case management visit to follow up on incident reports submitted to Community Care Licensing. LPAs were greeted and granted entry into the facility by Executive Director Foudil Manadi and explained the reason for the visit.

Incident report dated 11/17/2022 indicated Resident 1 (R) pushed the delayed egress button and exited into the parking lot. Memory Care Director was in the parking lot and observed the resident. Resident was redirected and assessed to have no injuries.

Incident report dated 12/02/2022 indicated R1 had exited through the back gate and alarm sounded. R1 was observed by another resident out walking. Resident brought R1 back to the Assisted Living lobby. R1 was assessed to have no injuries. Facility was not notified of incident until 12/08/2022 by staff.

During the visit, LPAs toured the memory care and spoke with R1. R1 appears happy and well taken care of. Per physician report dated 07/22/2022, R1 is diagnosed with Dementia with wandering tendencies. Facility is doing weekly elopement drills as well as additional activities to keep the resident engaged.

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: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
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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Document Has Been Signed on 12/14/2022 03:14 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: 12/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/15/2022
Section Cited

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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:
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Licensee to document a detailed written plan on how to ensure R1 does not elope out of the facility and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure basic services were provided to R1. R1 has eloped three times out of the facility. This poses an immediate health and safety risk to residents in care.
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
LIC809 (FAS) - (06/04)
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