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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002987
Report Date: 11/22/2024
Date Signed: 11/22/2024 05:01:37 PM

Document Has Been Signed on 11/22/2024 05:01 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:MISSION VIEJO CARE COTTAGES 2FACILITY NUMBER:
306002987
ADMINISTRATOR/
DIRECTOR:		MIGUELITO "BING" FAJARDOFACILITY TYPE:
740
ADDRESS:24142 DELPHI STREETTELEPHONE:
(949) 297-8948
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 4DATE:
11/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Bryan Estorba, AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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On this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Brandon Lopez made an
unannounced visit to the facility for the purpose of conducting the required annual inspection. LPAs were
greeted and granted entry by facility caregivers after introducing themselves and stating the purpose of the
visit. Administrator Bryan Estorba was notified by telephone and arrived later to assist with the visit.

LPAs accompanied by facility staff conducted a tour of the physical plant and observed the following: the
facility is a one-story home with an attached garage. The facility has four private bedrooms and one shared bedroom. All resident bedrooms have the required furnishings. LPAs observed all beds have linen and blankets. There are full rails used for postural support in two rooms. Physician orders for both were reviewed, along with the hospice plans of care. There is one shared bathrooms, which is observed to be equipped with grab bars and slip mats. Bathrooms faucets and toilets are operational. Water temperature was measured at 114.4F.

There are currently four residents admitted to the facility, including one admission who is currently in a skilled nursing facility for rehabilitation. There are two residents receiving hospice care. LPAs observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Drills are conducted quarterly and documented. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Some canned good in the garage are however observed to be expired. Type B citation issued. Smoke and carbon monoxide detectors tested operational. Fire extinguishers present is fully charged and has been maintained in 2024.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2024
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 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: MISSION VIEJO CARE COTTAGES 2
FACILITY NUMBER: 306002987
VISIT DATE: 11/22/2024
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CONTINUED FROM FORM LIC809
There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on
each side of the property, however one of the latching mechanism is stuck and does not allow passage. Type B citation issued. There are no bodies of water on the premises.

Cleaning products and sharp items are confirmed to be inaccessible throughout the physical plant. The medication central storage is however observed to have been left unlocked at the onset of the visit. Identically, the hospice comfort kits are stored in unlocked boxes in the attached garage, which is accessed through a door which can be easily unlocked. Type B citation issued. The medication central storage was reviewed to be accurate and up to date with the resident's prescription orders.

LPAs reviewed four resident files along with three staff records. Resident records include all necessary components. One admission agreement is missing one signature. Consultation provided. Review of the resident's records indicate a resident with diabetes who is stated to be self-administering their own insulin. Physician report review states the resident is not able to self-administer and monitor. Type B citation issued.
All staff members on the facility's roster are confirmed to be cleared and associated with this particular
licensed location. Training and CPR training verified to be up to date. Health screenings are on file for all staff members. COVID mitigation plan in use in lieu of Infection Control Plan. Consultation and form LIC9828 provided.

Based on the observations made during today’s inspection, four type B deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. One consultation provided.

An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility
representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/22/2024 05:01 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 11/22/2024 at 04:36 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: MISSION VIEJO CARE COTTAGES 2
FACILITY NUMBER: 306002987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation conducted during the visit, the licensee did not comply with the section cited above as one latching gate is stuck and cannot be opened easilty, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee will repair the gate and provide documentation of the repairs to LPA before the plan of corrections due date.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as expired canned goods were found to be present in the garage's pantry which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/25/2024
Plan of Correction
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Expired food items were disposed of during the visit.
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:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/22/2024 05:01 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 11/22/2024 at 04:38 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: MISSION VIEJO CARE COTTAGES 2
FACILITY NUMBER: 306002987

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the medication closet was observed to be unlocked and the hospice comfort kit were seen to be in non-secure plastic boxes in the garage's refrigerator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee will obtain a locking box for the comfort kit and conduct an update of the medication administration training, documentation of which will be provided to LPA before the plan of corrections due date.
Type B
Section Cited
CCR
87628(a)
Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record reviewed, the licensee did not comply with the section cited above as one resident with insulin-dependent diabetes is stated to self-administer even though their physician report states otherwise, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2024
Plan of Correction
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Licensee will seek to obtain an updated physician report reflecting the resident's ability to self-monitor their condition or implement measures ensuring the resident's injections are conducted by a skilled professional.
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:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2024


LIC809 (FAS) - (06/04)
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