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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002414
Report Date: 02/12/2025
Date Signed: 02/12/2025 04:04:59 PM

Document Has Been Signed on 02/12/2025 04:04 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:FREEDOM SPRINGS MANORFACILITY NUMBER:
306002414
ADMINISTRATOR/
DIRECTOR:		MAYLA MACHFACILITY TYPE:
740
ADDRESS:23235 CAVANAUGH RD.TELEPHONE:
(949) 716-1516
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 5DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Caregiver Yolanda RamirezTIME VISIT/
INSPECTION COMPLETED:
04:17 PM
NARRATIVE
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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. Administrator (AD) Mayla Mach was notified via telephone but could not arrive to assist due to being away on a vacation. LPA observed that Administrator Mayla Mach submitted a Administrator renewal application to the Administrator Certification Bureau (ACB) on November 18, 2024.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory and has a hospice waiver for three. The facility is a single-story home with six private resident bedrooms, one staff room, five resident bathrooms, two of which are shared, a living room, a dining room, a kitchen, and an attached two car garage. LPA accompanied by the caregiving staff conducted a tour of the interior portion of the facility. On today's visit, LPA observed five residents in care, four of which are on hospice, and two caregiving staff present. LPA observed residents relaxing in the living room as well as their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall by the entryway of the facility. LPA inspected all six 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 five 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 118.5 and 119.1 degrees Fahrenheit. LPA observed the staff room is kept locked and inaccessible to residents in care.

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. The electric stove top is operational. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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 5
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: FREEDOM SPRINGS MANOR
FACILITY NUMBER: 306002414
VISIT DATE: 02/12/2025
NARRATIVE
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LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed chemicals and toxins are stored in a locked kitchen cabinet under the sink. A fire extinguisher is located in the kitchen, and it was observed the be charged and purchased on January 24, 2025. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on December 9, 2024. The centrally stored medication is kept in a locked closet in the resident hallway. LPA observed a First Aid kit is stored in the locked closet and it was observed to have all the required components. The door leading to the attached two car garage is kept locked and inaccessible to resident in care. LPA observed the garage is used for storage and laundry. LPA observed the facility has a three day emergency food and water supply stored in the garage.

LPA and caregiver staff 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 gate on the north side and southside of the facility are self-latching and can be opened in an evacuation. There is a large pond located in the backyard. LPA observed the large pond to be adequately fenced and locked for resident safety.

LPA reviewed all five resident files. LPA observed that the Reappraisals for Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5) were outdated. LPA reviewed five residents’ medication and medication records. LPA observed that Resident #2 (R2) had a routine medication container that was empty ar time of visit. LPA observed that R2 did not receive the routine medication on 2/11/25 and 2/12/25 as a result. LPA reviewed three staff files. LPA observed that Staff #1 (S1) and Staff #3 (S3) did not receive the required annual training for the year of 2024. All staff are background cleared and associated to the facility.

Based on today's observations, deficiencies being cited per Title 22 of the California Code of Regulations. LPA spoke with Administrator Mayla Mach via telephone who authorized caregiving staff to sign the report. An exit interview was conducted with an authorized facility representative. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 02/12/2025 04:04 PM - It Cannot Be Edited


Created By: Brandon Lopez On 02/12/2025 at 03:12 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: FREEDOM SPRINGS MANOR
FACILITY NUMBER: 306002414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632(a)
In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. To obtain this waiver the licensee shall submit a written request for a waiver to the Department on behalf of any residents who may request retention, and any future residents who may request acceptance, along with the provision of hospice services in the facility. The request shall include, but not be limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in which poses a potential health, safety or personal rights risk to persons in care. LPA observed the facility currently has a hospice waiver for three. On today's visit, LPA observed that the facility currently has four residents receiving hospice care.
POC Due Date: 02/26/2025
Plan of Correction
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AD agreed to submit a hospice waiver increase to LPA via email or fax by POC date.
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:Sheila Santos
LICENSING EVALUATOR NAME:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/12/2025 04:04 PM - It Cannot Be Edited


Created By: Brandon Lopez On 02/12/2025 at 03:26 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: FREEDOM SPRINGS MANOR
FACILITY NUMBER: 306002414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. During residents' medication review, LPA observed that Resident #2 (R2) had a routine medication prescribed for Pantoprazone. However, LPA observed that the Pantoprazone medication container was empty and that the resident did not receive the medication for 2/11/25 and 2/12/25.
POC Due Date: 02/13/2025
Plan of Correction
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LPA observed caregiving staff order the medication for Resident #2 (R2) from their respective hospice agency. POC cleared at time of visit.
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:Sheila Santos
LICENSING EVALUATOR NAME:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/12/2025 04:04 PM - It Cannot Be Edited


Created By: Brandon Lopez On 02/12/2025 at 03:26 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: FREEDOM SPRINGS MANOR
FACILITY NUMBER: 306002414

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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. During staff file review, LPA observed that Staff #1 (S1) and Staff #3 (S3) did not complete any of the annual training required for the year of 2024.
POC Due Date: 02/26/2025
Plan of Correction
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AD agreed to provide Staff #1 and Staff #2 with the required annual training. AD agreed to submit proof of training to LPA via email or fax by POC date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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. During resident file review, LPA observed that the Reappraisals for Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5) were outdated.
POC Due Date: 02/26/2025
Plan of Correction
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AD agreed to complete Reappraisals for Resident #1 (R1), Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), and Resident #5 (R5). AD agreed to submit proof 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: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
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