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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005986
Report Date: 12/06/2022
Date Signed: 12/06/2022 11:47:48 AM


Document Has Been Signed on 12/06/2022 11:47 AM - 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:ACTIVCARE LAGUNA HILLSFACILITY NUMBER:
306005986
ADMINISTRATOR:SHETTER, TODD A.FACILITY TYPE:
740
ADDRESS:25200 PASEO DE ALICIATELEPHONE:
(858) 565-4424
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY:72CENSUS: 32DATE:
12/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Patricia Miller, Executive DirectorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at Activcare Laguna Hills to conduct an unannounced Required 1 Year Visit with an emphasis on Infection Control. At 10:13am, LPA Cho was greeted and granted entry by Receptionist Danna Miranda. LPA completed the Coronavirus 2019 (COVID-19) screening procedure and met with Executive Director (ED) Patricia Miller. There are no active COVID-19 cases as of today. LPA observed a mounted infrared thermometer and facility documents daily temperatures of visitors and completes the COVID-19 screening questionnaire via the tablet. LPA observed the required COVID-19 precautionary signs were posted throughout the facility. The Complaint Poster (PUB475) met the size requirement. The facility is licensed for seventy-two non-ambulatory residents of which seven may be bedridden and has a hospice waiver for fifteen. There are currently thirty-two residents living in the facility of which four are receiving hospice care.

Approximately 10:30am, LPA Cho conducted a tour of the physical plant with ED Miller. During the inspection the lights were turned off due to testing of the smoke/carbon monoxide detectors conducted by Louis Halper from First Choice Fire Protection. Due to the limitations, LPA was unable to get the reading of the hot water temperatures in the residents' rooms during the visit. LPA observed all residents sitting in the Great Room participating in activities which provided plenty of natural light. LPA observed all common areas and randomly selected and inspected a total of four resident apartments one per wing. The resident bedrooms had the required furnishings. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and non-skid mats were in place. Residents that shared a bathroom with a roommate did not have hand washing signs. All bathrooms had sufficient hand soaps and paper towels. Hand washing signs, hand soaps, and paper towels were observed in the public bathrooms in the common areas. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguishers were mounted, fully charged, and serviced on 09/06/2022.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
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: ACTIVCARE LAGUNA HILLS
FACILITY NUMBER: 306005986
VISIT DATE: 12/06/2022
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Smoke/carbon monoxide detectors were tested today and was operational. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. No body of water was present. There was shading and sufficient seating for residents. Walkways around the facility were clear of hazards, and there were no security bars or weapons on the premises. LPA observed sufficient supply of emergency food/water and PPEs.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. An Advisory Note (LIC9102) was issued during the visit.

An exit interview was conducted with Executive Director Patricia Miller, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2022
LIC809 (FAS) - (06/04)
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