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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001261
Report Date: 02/16/2022
Date Signed: 02/16/2022 04:24:47 PM

Document Has Been Signed on 02/16/2022 04:24 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:LAKE FOREST COUNTRY HOME IIIFACILITY NUMBER:
306001261
ADMINISTRATOR:RIVAS, CARMEN T.FACILITY TYPE:
740
ADDRESS:22741 COSTA BELLATELEPHONE:
(949) 472-8711
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 5DATE:
02/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Roselinda SitanggangTIME COMPLETED:
01:12 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. Staff contacted via phone call Administrator (AD) Carmen Rivas who stated she would not be able to attend the visit today. AD Rivas stated caregiver Rosdiana could sign the report today. AD Carmen Rivas has a current administrators certificate that expires on 02/16/2022. LPA observed a screening station equipped with mask, and sanitizer. LPA observed a screening log book, and temperature thermometer for screening clients and visitors. At 10:35am LPA toured the facility with caregiver Rosdiana. There were five residents in care at the facility. All appeared to be happy and well taken care of. LPA began the tour checking client rooms and bathrooms. Client rooms have the necessary requirements, night stand, chair, lamp and dresser. Bathrooms were operational and clean. In Bathroom #1 LPA measured the water temperature at 113.3F degrees. In Bathroom #2 LPA measured the water temperature at 117.5F degrees. The facility had a two day supply of perishable food items and seven days supply of nonperishable food items. There was a first aid kit equipped with all required items. The stove was clean and all four burners were operational. Knives were kept locked in a drawer in the kitchen. All medications were locked in a drawer in the kitchen. All hazardous chemical are locked under the sink. The facility has adequate PPE supply. LPA observed extra linen, emergency food and water supply. LPA toured the backyard and observed both side exit gates of the house were self closing and self latching. LPA observed a shaded visitation area in the backyard equipped with tables and chairs for the residents in care. There were no bodies of water observed. Wired smoke detectors were tested and are operational. Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8. A copy of the LIC809d and LIC9102 were explained and provided to caregiver Rosdiana during the visit. An exit interview conducted and a copy of the appeal rights were given to the caregiver at time of visit. A copy of the report was provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2022
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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Document Has Been Signed on 02/16/2022 04:24 PM - It Cannot Be Edited


Created By: Jerome Haley On 02/16/2022 at 12:14 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LAKE FOREST COUNTRY HOME III
FACILITY NUMBER: 306001261

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(a)(e)(1)


This requirement is not met as evidenced by: LPAs observation and the infromation provided to LPA Haley by staff at the facility. Upon calling the Regional Office for verification LPA Haley was informed there is no Criminal Record Clearance for Nathaniel.
Deficient Practice Statement
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Based on observation and interview with staff, the licensee did not comply with the section cited below:
87355 Criminal Record Clearance
(a) the department shall conduct a criminal record review of all individuals specified in Health and safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence or prescense in the facility, based on the results of such review.
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department
POC Due Date: 02/17/2022
Plan of Correction
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Licensee will ensure all employees have a criminal record clearance before being allowed to work, or volunteer at the facility.
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:Luz Adams
LICENSING EVALUATOR NAME:Jerome Haley
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022


LIC809 (FAS) - (06/04)
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