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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003634
Report Date: 02/07/2023
Date Signed: 02/07/2023 02:59:06 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230127091721
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: 4DATE:
02/07/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lourdes Rivero, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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1/ Staff are not trained.

INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegation listed above. LPA Saborit-Guasch was greeted and granted entry by caregiving staff present after explaining the purpose of the visit. Administrator Lourdes Rivero was notified by telephone and arrived later to assist with the visit.

On February 1, 2023, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced initial complaint investigation visit at the facility. Staff and resident records were reviewed alongside staff schedules. Interviews conducted with staff members and administrator.

On February 6 and 7, 2023, Administrator Lourdes Rivero followed up via email to indicate that the training vendor used by the facility for staff training was unable to retrieve former records. Therefore annual training updates and initial training session for all three current staff members could not be fully documented.
CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2023 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230127091721

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: 4DATE:
02/07/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lourdes Rivero, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
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8
9
2/ Uncleared staff are providing care and supervision to residents.

3/ Facility administrator is absent from the facility.

4/ Staff not wearing masks.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the three allegations listed above. LPA Saborit-Guasch was greeted and granted entry by caregiving staff present after explaining the purpose of the visit. Administrator Lourdes Rivero was notified by telephone and arrived later to assist with the visit.

On February 1, 2023, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced initial complaint investigation visit at the facility. Staff and resident records were reviewed alongside staff schedules. Interviews conducted with staff members and administrator.

Follow-up correspondence and documentation was provided by administrator via email on February 6 and February 7, 2023.

CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20230127091721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CASA DEL LAGO
FACILITY NUMBER: 306003634
VISIT DATE: 02/07/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099-A

On February 7, 2023, LPA conducted a follow-up investigation visit. Follow-up interviews were conducted with staff members S2 and S3 as well as with administrator.

Regarding the allegation that Uncleared staff are providing care and supervision to residents, the following has been determined: During both visits, all staff members present were found to be adequately cleared and associated in Guardian. Interviews conducted confirmed the identity of other scheduled staff members who were not present at the time of the visit but were also confirmed to be cleared and associated. The allegation is therefore found to be unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Regarding the allegation that Facility administrator is absent from the facility, the following has been determined: During both visits, interviews and a review of staff schedules on file confirmed the daily presence of administrator for at least two to three hours, often more, depending on the established needs at the time. During both visits, Administrator was able to come to the facility under short notice and assist with the investigation's requests.The allegation is therefore found to be unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Regarding the allegation that Staff is not wearing masks while providing care and supervision a the facility, the following has been determined: During both visits, staff members and administrator were observed wearing masks already at the onset of the visits and continuously throughout the LPA's presence at the facility over several hours. The allegation is therefore found to be unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was provided and left at the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 22-AS-20230127091721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CASA DEL LAGO
FACILITY NUMBER: 306003634
VISIT DATE: 02/07/2023
NARRATIVE
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CONTINUED FROM FORM LIC9099

Furthermore, interviews conducted during the visits confirmed that initial training may not have been fully completed for some of the more recent hires. The absence of documentation establishing otherwise further corroborates that some employees may have been missing part of their required training at the time of the initial visit.

Following the initial visit, Administrator stated and provided documentation for medication administration training as well as required dementia training being conducted.

On February 7, 2023, LPA conducted a follow-up investigation visit. Follow-up interviews were conducted with staff members S2 and S3 as well as with administrator.

Based on observation, interviews conducted and a review of records provided at the facility, the allegation that Staff are not trained is deemed Substantiated, meaning that the preponderance of evidence standard has been met.

One deficiency is cited today per Title 22, Division 6, of the California Code of Regulations.

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

DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 22-AS-20230127091721
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CASA DEL LAGO
FACILITY NUMBER: 306003634
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/07/2023
Section Cited
CCR
87411(c)(6)
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The California Code of Regulations Section 87411(c)(6) Personnel Requirements - General indicates that "The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2)"

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Licensee to schedule make up sessions of the missing initial and/or annual training sessions and provide documentation of completion before the Plan of Corrections due date.
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This requirement is not met as evidenced by the fact that licensee is unable to provide proof of some initial or annual training for staff.
Based on records reviewed, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5