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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001261
Report Date: 01/23/2024
Date Signed: 01/23/2024 02:49:01 PM

Document Has Been Signed on 01/23/2024 02:49 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: 6DATE:
01/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Staff on duty - Melanie MasecampoTIME COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by staff on duty (S1) Melanie Masecampo. S1 Masecampo notified facility administrator (AD) Carmen Rivas about the visit, however AD was unable to be present, therefore, provided consent for S1 Masecampo to receive and sign the report.

For today’s visit, LPA observed a total of 6 residents in care and 2 staff members on duty,

LPA observed the Administrator's Certificate for facility administrator (AD) Carmen Rivas which expires on 02/16/2024.

LPA De Perio toured the interior and exterior portions of the facility with S1 Masecampo. The facility is a single level structure and is licensed for 6 non-ambulatory residents, of which 2 may be on hospice and 0 bedridden. For this visit, there are a total of 6 residents in care. There are a total of 6 bedrooms, of which are 4 private resident rooms, 1 shared resident room and 1 private room for staff. LPA De Perio toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 3 restrooms of which 1 is for staff and 2 are for residents. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured to be at 110.7 degrees Fahrenheit.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: LAKE FOREST COUNTRY HOME III
FACILITY NUMBER: 306001261
VISIT DATE: 01/23/2024
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Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen.

LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the kitchen. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components. LPA De Perio observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which both were self-closing and self-latching. No bodies of water were observed.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

An exit interview was conducted with S1 Masecampo and AD Rivas via phone call.

A copy of this report was provided and explained.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC809 (FAS) - (06/04)
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