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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880782
Report Date: 10/18/2024
Date Signed: 10/18/2024 04:40:48 PM

Document Has Been Signed on 10/18/2024 04:40 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:MIMOSA HIGHPOINTEFACILITY NUMBER:
331880782
ADMINISTRATOR/
DIRECTOR:		STEWART, LEONAFACILITY TYPE:
735
ADDRESS:15160 MIMOSA DRTELEPHONE:
(562) 682-0946
CITY:LAKE ELSINORESTATE: CAZIP CODE:
92530
CAPACITY: 4CENSUS: 3DATE:
10/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Administrator Adegboyega Agbelusi and House Manager Maureen SevillaTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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On 10/18/2024 at 12:45 PM, Licensing Program Analyst (LPA) Melody Brown arrived unannounced to conduct the required comprehensive annual visit to the facility. LPA met with a staff, introduced self and stated the purpose of the visit. Administrator Adegboyega Agbelusi was contacted and arrived during the visit. Also, House Manager Maureen Sevilla and Residential Director Courtney Moore arrived during the visit.

The facility has four (4) bedrooms, two (2) bathrooms, kitchen, dining room, living room, laundry room, attached garage. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, medication audit and P&I audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), LPA Brown observed three (3) clients. There are no obstructions to indoor passageway, but LPA Brown observed obstruction in the outdoor passageway of the facility. LPA Brown observed obstructions to outdoor passageway as evidenced of wood with rusted and sharp nails and rusted metal at the outdoor passageway. Deficiency will be issued. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, storage space, chairs, night stands and sufficient lighting. However, LPA Brown observed Client #1 (C1) with full bed rail and per interview and records review, C1's not on hospice and no exception letter was submitted and approved by CCLD. Deficiency will be issued. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional, however, LPA Brown observed no non-slip mat in the client shared bathroom. Deficiency will be issued. Water temperatures tested at 122.7 degrees Fahrenheit. Deficiency will be issued. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, labor laws, personal rights, emergency disaster plan were posted in a common area. ***Continuation in LIC809C***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782
VISIT DATE: 10/18/2024
NARRATIVE
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Sharps and medications were kept in secure cabinets inaccessible to clients. However, LPA Brown observed two (2) bottle sprays of cleaning solutions and one (1) bottle spray of bleach under the sink, not locked and accessible to clients in care. Deficiency will be issued. In addition, LPA Brown observed window screens and screen door in disrepair. Technical Violation issued. LPA Brown observed no night lights maintained in hallways and passages to non-private bathrooms. Deficiency will be issued. LPA Brown observed the two (2) outdoor chairs in disrepair. Deficiency will be issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard. The outdoor pathway on the side of the facility was not free of obstruction as evidenced of wood with rusted and sharp nails and rusted metal at the outdoor passageway. Deficiency will be issued.

Food Service: LPA observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.



Record Review: LPA Brown reviewed client files for Admission Agreements, Medical Assessment/Physician Report (LIC602), Individual Program Plan (IPP), Centrally Stored Medication List. LPA Brown observed that Client #3 (C3) Admission Agreement was not signed by the Licensee or facility representative. Deficiency will be issued. LPA Brown also reviewed staff and administrator's file for First Aid/CPR and CPI certification, criminal record clearance, trainings, and health screenings with Tuberculosis (TB) Test result. LPA Brown observed that files reviewed were complete. LPA Brown audited three (3) client medications, and no issues observed. LPA Brown audited two (2) client Personal and Incidental (P & I) and no issues observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809D, LIC9102 and Appeal Rights were discussed and copies were provided to Administrator Adegboyega Agbelusi and House Manager Maureen Sevilla.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 10/18/2024 04:40 PM - It Cannot Be Edited


Created By: Melody Brown On 10/18/2024 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's no obstruction in the outdoor passageway as evidenced of wood with rusted and sharp nails and rusted metal observed at the outdoor pasageway which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2024
Plan of Correction
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Licensee stated to remove the wood with rusted and sharp nails and rusted metal observed at the outdoor pasageway an dsubmit proof to LPA Brown on Plan of Correction (POC) due date. Licensee stated to train all staff on CCR 80087(c) and submit proof of all staff training log to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the two (2) bottle sprays of cleaning solutions and one (1) bottle spray of bleach under the sink, was locked and not accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2024
Plan of Correction
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Licensee immediately locked the observed two (2) bottle sprays of cleaning solutions and one (1) bottle spray of bleach under the sink during the visit. Licensee stated to train all staff on CCR 80087(g) and submit proof of all staff training log to LPA Brown on Plan of Correction (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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 10/18/2024 04:40 PM - It Cannot Be Edited


Created By: Melody Brown On 10/18/2024 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(8)(E)1
Personal Rights
1. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. Bed rails that extend the entire length of the bed are prohibited except for clients who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by allowing Client #1 (C1) to have full bed rail and C1's not on hospice and no letter was submitted and approved by CCLD for C1's full bed rail which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/19/2024
Plan of Correction
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Licensee removed the full bed rail during the visit. Plan of Correction (POC) cleared.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 10/18/2024 04:40 PM - It Cannot Be Edited


Created By: Melody Brown On 10/18/2024 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(b)(1)
Building and Grounds
(b) All clients shall be protected against hazards within the facility through provision of the following: (1) Protective devices including but not limited to nonslip material on rugs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's a non-slip mat in client's shared bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee stated to purchase non-slip mat and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not regulating the hot water in client's shared bathroom to ot less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee regulated the hot water temperature to 111 degrees Fahrenheit during the visit. Plan of Correction (POC) cleared.
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 10/18/2024 04:40 PM - It Cannot Be Edited


Created By: Melody Brown On 10/18/2024 at 03:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that night lights are mainatained in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee stated to purchase the required night lights and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
85087.2(b)
Outdoor Activity Space
(b) The outdoor activity area shall provide a shaded area, and shall be comfortable, and furnished for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the two (2) outdoor chairs are in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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2
3
4
Licensee stated to purchase outdoor chairs and submit proof to LPA Brown on 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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 10/18/2024 04:40 PM - It Cannot Be Edited


Created By: Melody Brown On 10/18/2024 at 04:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: MIMOSA HIGHPOINTE
FACILITY NUMBER: 331880782

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(e)
80068 Admission Agreements (e) Such agreements shall be dated and signed, acknowledging the contents of the document, by the client and the client's authorized representative and the licensee or the licensee's designated representative no later than seven calendar days following admission.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Client #3 (C3) Admission Agreement was signed by the Licensee or Licensee Representative which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2024
Plan of Correction
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Licensee signed C3 Admission Agreement during teh visit. POC cleared.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:Efren Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024


LIC809 (FAS) - (06/04)
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