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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001261
Report Date: 01/16/2025
Date Signed: 01/16/2025 12:04:12 PM

Document Has Been Signed on 01/16/2025 12:04 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LAKE FOREST COUNTRY HOME IIIFACILITY NUMBER:
306001261
ADMINISTRATOR/
DIRECTOR:		RIVAS, CARMEN T.FACILITY TYPE:
740
ADDRESS:22741 COSTA BELLATELEPHONE:
(949) 472-8711
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
01/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:05 AM
MET WITH:Licensee Carmen RivasTIME VISIT/
INSPECTION COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by caregiving staff after explaining the purpose for the visit. Licensee Carmen Rivas was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Alan Shelley has a valid Administrator certificate which expires on March 24, 2025.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents with a hospice waiver for two. The facility is a single-story home with five resident bedrooms, one staff room, two shared resident bathrooms, a living room, a dining room, a kitchen, and an unattached two car garage. LPA accompanied by the Licensee conducted a tour of the physical plant. On today's visit, LPA observed six residents in care, none of which are on hospice, and two caregiving staff present. LPA observed residents eating their breakfast in the dining room. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall by the entryway of the facility. LPA inspected the five resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA observed additional linens are stored in a hallway closet. LPA inspected the two shared resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 116.7 and 118.9 degrees Fahrenheit.

LPA observed the kitchen has a two-day perishable and seven-day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed cleaning supplies are stored in a locked kitchen cabinet under the sink. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/16/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LAKE FOREST COUNTRY HOME III
FACILITY NUMBER: 306001261
VISIT DATE: 01/16/2025
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A fire extinguisher is located in the kitchen, and it was observed the be charged and serviced as of July 31, 2024. LPA tested the wired smoke detector/carbon monoxide detector which tested operational. LPA observed the facility conducted their last emergency disaster drill on December 15, 2024.The centrally stored medication is kept in a locked cabinet in the kitchen. LPA observed the First Aid kit has all the required components. The unattached two car garage is kept locked and inaccessible to resident. The garage is used for storage and laundry. LPA observed the facility has an emergency food and water supply stored in the garage.

LPA and Licensee conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gates on the northside and southside of the facility are self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed all six resident files. LPA observed that Resident #2 (R2) did not have a Medical Assessment on file. LPA observed that Resident #1 (R1) and Resident #2 (R2) did not have an Admission Agreement on file. LPA reviewed six residents’ medication and medication records. LPA reviewed three staff files. All staff are background cleared and associated to the facility.

Based on today's observations, there are deficiencies being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Licensee Carmen Rivas. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/16/2025 12:04 PM - It Cannot Be Edited


Created By: Brandon Lopez On 01/16/2025 at 11:38 AM
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: 01/16/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health and safety risk to persons in care. During file review, LPA observed Resident #2 (R2) did not have a medical assessment on file.
POC Due Date: 01/24/2025
Plan of Correction
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Licensee agreed to submit a completed Medical Assessment for Resident #2 to LPA via email or fax by POC date.
Type B
Section Cited
CCR
87507(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. Per file review, LPA observed that Resident #1 (R1) does not have an Admission Agreement on file.
POC Due Date: 01/24/2025
Plan of Correction
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Licensee agreed to submit a completed Admission Agreement for Resident #1 to LPA via email or fax by POC 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:Sheila Santos
LICENSING EVALUATOR NAME:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/16/2025


LIC809 (FAS) - (06/04)
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