306005689-9-16-2022-22-AS-KSGH-CJBU86-20220916152100

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005689
Report Date: 09/16/2022
Date Signed: 09/16/2022 03:21:37 PM

Document Has Been Signed on 09/16/2022 03:21 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:	FLORESTA COTTAGE		FACILITY NUMBER:	306005689
ADMINISTRATOR:	ANGELES, OFELIA		FACILITY TYPE:	740
ADDRESS:	26982 FLORESTA LANE		TELEPHONE:	(714) 553-6849
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 3	DATE:	09/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Eric Esguerra, House manager		TIME COMPLETED:	03:45 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	On 09/16/2022 at 2:00pm, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Alvaro Ramirez made an unannounced visit to the facility in order to conduct a required annual inspection focusing on Infection Control procedures. LPAs were greeted and granted entry by Ellin Sinaga, caregiver and explained the purpose of the visit. House manager Eric Esguerra was notified by text message and arrived later to assist with the visit. At approximately 2:15pm, LPAs accompanied by caregiver toured the physical plant of the facility. There are currently three (3) residents in care, none of which are receiving hospice care. Residents are observed relaxing in their respective bedrooms and appear clean and well taken care of. Licensing staff spoke with two of the residents who stated that they were fully satisfied with the care provided at the facility. The six individual bedrooms include all necessary components. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected. An ample supply of linen is observed. Most of the sharp instruments are kept in a secured cabinet in the kitchen, however a few were left in one of the drawers. The centrally stored medication is located in another kitchen cabinet with a plastic child-proof lock. Cabinet was initially left open at the time of the visit. A 30-day supply of medication is observed. LPAs observed a sufficient supply of food and water present. LPA observed the facility has COVID-19 Precautions posters and all required department postings. A check-in station is observed at the facility's entrance. Staff present is adequately cleared and associated in Guardian. CONTINUED ON FORM LIC809-C

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

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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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: FLORESTA COTTAGE	FACILITY NUMBER: 306005689
	VISIT DATE: 09/16/2022

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CONTINUED FROM LIC809

LPA and caregiver toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and a shaded area are present for the enjoyment of residents and visitors. A storage shed is also present. The perimeter gates on both sides of the facility are self-latching and can easily be opened in an evacuation. There is a fenced swimming pool on the premises, the gate of which being unlocked in compliance with Department regulations.

Based on the observations made during today’s visit, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report and appeal rights was provided and left at facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/16/2022 03:21 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: FLORESTA COTTAGE	FACILITY NUMBER: 306005689
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)(1)

California Code of Regulation Section 87705(f)(2) Care of Persons with Dementia "The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s)." This requirement is not met as evidenced by: The cabinet and drawer where sharp instruments are stored is stated by staff to only be locked at night. The same statement is made regarding the attached garage containing more cleaning supplies and dangerous objects.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2022
	Plan of Correction
1 2 3 4	Licensee will provide in-service training to reaffirm the necessity of securing sharp instruments and potential toxic substances at all times. Documentation of the training will be submitted to LPA before the Plan of Corrections due date.

Type B

Section Cited

CCR

87465(h)(2)

The California Code of Regulation section cited above indicates that "Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication." This requirement is not met as evidenced by: The child-proofing lock on the medicine storage door was observed to be left unlocked when licensing staff arrived at facility and was only closed later by the caregiving staff during the visit.
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/30/2022
	Plan of Correction
1 2 3 4	Licensee wil provide in-service training to remind all staff members of the requirements of the regulation quoted above for the health ad safety of the individuals in care.

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 Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch	TELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022

LIC809 (FAS) - (06/04)

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