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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003634
Report Date: 03/24/2022
Date Signed: 03/24/2022 01:23:39 PM

Document Has Been Signed on 03/24/2022 01:23 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:CASA DEL LAGOFACILITY NUMBER:
306003634
ADMINISTRATOR:RIVERO, LOURDESFACILITY TYPE:
740
ADDRESS:27332 ALLARIZTELEPHONE:
(949) 716-4497
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 3DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Administrator Lourdes RiveroTIME COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection to this facility. LPA met with Administrator (AD) Lourdes Rivero; and stated the purpose of this visit.

This facility is a single level structure and licensed for 6 non-ambulatory; and with hospice waiver for two. On this visit, there was no resident under hospice care.

About 12:10 PM , LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, there were three residents in care and one staff on the floor. LPA toured the interior and exterior portions of the facility. There were two private and two shared resident's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were provided with handrails and nonskid-floor mat. Hot water was measured at 120 degrees Fahrenheit. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair. Grounds were free of tripping hazards. Side exit doors were self closing and self latching. LPA Marin reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. LPA also discussed with AD to maintain safe environment for residents in care while the facility is undergoing remodelling and repair. Administrator Certificate of AD Rivero is valid until July 20, 2022.

For this visit, no citation was issued.

LPA Marin conducted an exit interview with AD L. Rivero; and copy of this report was left in the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Albert Marin
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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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