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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005585
Report Date: 07/16/2024
Date Signed: 07/16/2024 05:17:58 PM


Document Has Been Signed on 07/16/2024 05:17 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:VIVIDUS SENIOR LIVINGFACILITY NUMBER:
306005585
ADMINISTRATOR:SHARIFAN, BAABAKFACILITY TYPE:
740
ADDRESS:25131 VIA PORTOLATELEPHONE:
(949) 777-5369
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 6DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Edgardo SevillaTIME COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA explained the reason for the visit. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA and staff toured the facility. Facility is a single story home with an attached 2 car garage with 5 bedrooms, 3 bathrooms, kitchen, dining room and a living room with a fireplace. LPA observed the fireplace is screened. The fire extinguisher in the kitchen is charged. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed that the front left burner on the 4 burner gas burner stove does not light unassisted. LPA observed knives are kept locked under the kitchen sink. LPA observed the medications are kept locked in a kitchen cabinet. LPA and staff toured the resident rooms. 4 of the resident rooms are private and one is shared. LPA observed all resident rooms are clean and organized. All resident rooms had the required furnishings and bed linens. LPA toured the garage. The garage is kept locked and used for storage of extra supplies and food. Smoke detectors/carbon monoxide detectors tested operational. LPA observed all 3 bathrooms are clean and operational. Hot water measured 105.8 degrees Fahrenheit in all 3 bathrooms. LPA and staff toured the backyard. No bodies of water observed. There is a table with an umbrella and chairs for residents to sit outside. Both exit gates are operational. No obstacles or hazards observed in the backyard. LPA reviewed 6 resident files. 1 out of 6 residents did not have a current medical assessment (LIC 602A, physician's report). Resident 2 (R2) did not have a current physician's report. LPA reviewed 6 resident medications, no discrepancies observed. LPA reviewed 4 staff files. 2 out of 4 staff did not have the required 20 hours of annual training. Staff 1 (S1) and Staff 2 (S2) did not have any current annual training. All 4 staff members had current CPR/First Aid training. No other discrepancies observed. Deficiencies are being cited per Title 22 division 6 of the California Code of Regulations. An exit interviewed was conducted and a copy of the report along with appeal rights was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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 07/16/2024 05:17 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: VIVIDUS SENIOR LIVING
FACILITY NUMBER: 306005585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
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 observation, the licensee did not comply with the section cited above, LPA observed the front left burner of the 4 burner gas stove cannot light unassisted which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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Licensee agrees to have the stove repaired or replaced so that all 4 burners can light unassisted. Licensee to forward proof to LPA by POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
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 record review, the licensee did not comply with the section cited above in 2 out of 4 staff members, LPA reviewed 4 staff files and observed that staff 1 and staff 2 did not have any current training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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Licensee agrees to have staff 1 and staff 2 trained to meet the regulation requirements. Licensee agrees to forward proof of training to the LPA by the 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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/16/2024 05:17 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: VIVIDUS SENIOR LIVING
FACILITY NUMBER: 306005585

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 6 resident files, LPA observed that resident 2 (R2) did not have a current medical assessment and they have diagnosed with Dementia, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/01/2024
Plan of Correction
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Licensee agrees to have a new medical assessment (LIC 602A) completed for resident 2 and to submit proof to LPA by the 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.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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