306001261-1-30-2026-22-AS-WVAS-DQU2KB-20260130162739

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001261
Report Date: 01/30/2026
Date Signed: 01/30/2026 04:27:50 PM

Document Has Been Signed on 01/30/2026 04:27 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 III		FACILITY NUMBER:	306001261
ADMINISTRATOR/ DIRECTOR:	RIVAS, CARMEN T.		FACILITY TYPE:	740
ADDRESS:	22741 COSTA BELLA		TELEPHONE:	(949) 472-8711
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 6		CENSUS: 4	DATE:	01/30/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:27 PM
MET WITH:	Carmen Rivas (Licensee)		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On this date January 30, 2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by facility staff after explaining the purpose for the visit. Licensee Carmen Rivas was present to assist with the inspection.LPA observed that Administrator Diane Antonini has a valid Administrator certificate which expires on May 29, 2026. LPA began a tour of the facility and observed the following. 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 observed four residents in care, none of which are on hospice, and two caregivers present. LPA observed residents in the living room and their bedrooms. 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, reading lamp, and enough storage space to store personal belongings. All resident beds had clean linens in good repair; meaning no strains or tears. 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, slip resistant floor mats, and shower chairs. Faucets and toilets were operational. Hot water temperature measured between 115.8 and 117.4 degrees Fahrenheit. LPA observed kitchen area to be clean, and free of any mildew and debris. LPA observed the facility to have 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

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 01/30/2026

NARRATIVE

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LPA observed all smoke detectors and carbon monoxide detectors to be in good repair and operational. LPA observed all fire extinguishers to be fully charged, and up to date. LPA Vanegas observed first aid kit to have all required items such as adhesive tape, scissors, bandages, tweezers, a thermometer, and a first aid manual. LPA conducted a tour of the outside of the facility and observed the following. There is an outdoor shaded seating area, no hazards or objects were observed along the sides of the exit routes. Side doors were unlocked and self latching.

LPA Vanegas reviewed four resident files, and two staff files all resident files had all required documents, however two staff files that were reviewed did not have the required training a deficiency was issued on today's date. LPA reviewed medication administration log and medications with licensee, per LPA review no discrepancies were found, and medications are being administered per physicians orders. Based on observations made during today's inspection deficiencies will be issued. An exit interview was conducted with Licensee Carmen Rivas, and a copy of this report was provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: William Vanegas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/30/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/30/2026 04:27 PM - It Cannot Be Edited

Created By: William Vanegas On 01/30/2026 at 04:10 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: 01/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(a)(2)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two out of two staff on duty did not have the required training completed and documented, which poses safety risk to persons in care.
	POC Due Date: 02/13/2026
	Plan of Correction
1 2 3 4	Licensee agrees to conduct and complete training for staff on duty, and send proof of correction to LPA Via email by P.O.C due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 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.

	Armando J Lucero
NAME OF LICENSING PROGRAM MANAGER:

	William Vanegas
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/30/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026

LIC809 (FAS) - (06/04)

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