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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003492
Report Date: 09/17/2021
Date Signed: 09/17/2021 02:14:46 PM

Document Has Been Signed on 09/17/2021 02:14 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:CASTILLA LANE VILLAFACILITY NUMBER:
306003492
ADMINISTRATOR:DIZON, EMMANUELFACILITY TYPE:
740
ADDRESS:24272 CASTILLA LANETELEPHONE:
(949) 716-8779
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 2DATE:
09/17/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Administrator Emmanuel Dizon TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to this facility to conduct a case management visit. LPA was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedures. Via phone, LPA spoke to Administrator Sherry Dizon and stated the purpose of the visit. Shortly after, Administrators (AD) Emmanuel Dizon and Sherry Dizon arrived in the facility.

On September 16, 2021, Community Care Licensing Division (CCLD) Orange Office received an incident report from the facility stating that Resident 1 got out of the facility without assistance.

For this visit, LPA Marin toured the interior and exterior portions of the facility. LPA observed two residents in care and two staff members on the floor. LPA tested auditory exit alarms and all were observed to be operational. LPA also observed motion sensors scattered in common exits of the facility. LPA reviewed facility files. Per file review of Resident 1's physician report issued last August 7, 2021, Resident 1 has primary diagnosis of Dementia, and indicated not able to leave the facility unassisted.

For this visit, deficiency was observed and citation was issued per Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD E. Dizon. LPA discussed the deficiency, citation and appeal rights. LPA left copies of this report, Deficiency (809-D), appeal rights, and copy of cited regulations in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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Document Has Been Signed on 09/17/2021 02:14 PM - It Cannot Be Edited


Created By: Albert Marin On 09/17/2021 at 01:37 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: CASTILLA LANE VILLA
FACILITY NUMBER: 306003492

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2021
Section Cited
CCR
87705(b)(2)

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87705 Care of Persons with Dementia... In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering.. This requirement was not met as evidenced by:
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AD had replaced better auditory exit alarm, and also used motion sensors throughout the facility. Resident 1 had recent consultation with primary physician. Threat was reduced. AD agreed to offer regular training and strategies to staff to address wandering behavior of residents diagnosed with neurocognitive disorders. (Continuation below)
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Based on observation, file review and interviews, facility missed to provide safety measures to address the wandering behavior of the residents. Resident 1 was able to leave the facility without assistance. This posed immediate threat on the safety of the resident in care.
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Deficiency was corrected at the time of the visit.

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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:Luz Adams
LICENSING EVALUATOR NAME:Albert Marin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2021


LIC809 (FAS) - (06/04)
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