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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003634
Report Date: 03/05/2025
Date Signed: 03/05/2025 01:51:12 PM

Document Has Been Signed on 03/05/2025 01:51 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:CASA DEL LAGOFACILITY NUMBER:
306003634
ADMINISTRATOR/
DIRECTOR:		RIVERO, LOURDESFACILITY TYPE:
740
ADDRESS:27332 ALLARIZTELEPHONE:
(949) 716-4497
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
03/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Lourdes Rivero- AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Required 1-Year annual evaluation using the Care Inspection Tool. LPA was greeted and granted entry by Caregiver Azalia Ayala and explained the reason for the visit. Administrator (Admin) Lourdes Rivero arrived on premise to assist with the inspection. Administrator Rivero has a valid administrator's certificate expiring on July 30, 2026.

The facility is a single story structure and is licensed to operate for six non-ambulatory residents and has a hospice waiver for two residents. Based on observation, there are two staff on duty caring for six residents of which three are in hospice care. It is determined that facility is operating beyond the conditions and limitations specified on the license by exceeding the number of hospice residents that can be accepted at one time. During the walk through, LPA observed four resident bedrooms and two and a half resident bathrooms. Resident bedrooms had all required furnishings. LPA observed the following issues in the bedrooms: Resident #5 (R5) did not have a bed rail order and the window screen in the bedroom of Resident #4 (R4) has a tear that needs to be repaired. Bathrooms were found to be in compliance, clean, and operational. The hot water temperature measured at 109.4, 107.0, and 107.7 degrees Fahrenheit. All common areas were inspected including the attached two car garage. LPA observed sufficient emergency food and water in the garage. LPA did not observe a generator and/or emergency lights as indicated on the Emergency Disaster Plan (LIC 610D). Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available in the kitchen and garage. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. Both exit gates were self-closing and self-latching. LPA observed sufficient seating and shading. The fire extinguisher was charged, mounted, and serviced on April 22, 2024. The auditory devices dual functioning smoke/carbon monoxide detectors were tested and operational. The auditory device in the master bedroom sliding door was not operable.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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 03/05/2025 01:51 PM - It Cannot Be Edited


Created By: Jessica Cho On 03/05/2025 at 12:09 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: CASA DEL LAGO
FACILITY NUMBER: 306003634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above in which facility is providing care and supervision to three hospice residents when approved for two which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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Administrator stated that hospice waiver requesting an increase with the supporting documents as discussed during the exit interview will be suibmitted to LPA via email by POC due 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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
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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: CASA DEL LAGO
FACILITY NUMBER: 306003634
VISIT DATE: 03/05/2025
NARRATIVE
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Emergency evacuation drills are conducted quarterly. Last known drill was conducted on February 23, 2025 at 2:00pm per review of the log. The first aid kit contains all necessary elements. The facility land line number, (949) 716-4497, was tested and remains available. The liability insurance is valid expiring on March 12, 2025. Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the incorrect size of 8.5"x11."

LPA conducted a file review of all residents and two staff. Discrepancies noted with staff files. Two out of the two staff did not posses a CPR/First Aid Training certificate. Medications were audited. No concerns. Interviews were conducted.

The following items were addressed during the exit interview: to post the license and Complaint Poster (PUB 475) in the correct size, to repair the window screen tear in R4's bedroom, replace the battery for the auditory device on the sliding door of the master bedroom, cover the exposed wire in the ceiling of the hallway, amend the LIC610D as well as complete page 9, conduct quarterly drills of various emergency scenarios per shift, obtain a full bed rail order for R5, ensure at least one staff on duty per shift possesses a CPR/First aid certificate, to submit a hospice waiver to the Department requesting an increase in hospice as the facility is currently approved to accept two hospice residents, and to pay the annual dues due on March 30, 2025.

Based on the observations made during today's visit, deficiencies are being cited. Advisory Notes (LIC9102s) are also being issued.

An exit interview was conducted with Administrator Lourdes Rivero, and a copy of this report (LIC809/LIC809-C), LIC809-Ds, LIC9102s, LIC811s, appeal rights, and a copy of the regulation Hospice Care Waiver 87632 were provided at the end of the visit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/05/2025 01:51 PM - It Cannot Be Edited


Created By: Jessica Cho On 03/05/2025 at 01:33 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: CASA DEL LAGO
FACILITY NUMBER: 306003634

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(3)
87608 Postural Supports (a) (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews, and record review, the licensee did not comply with the section cited above in one out of the six residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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Adminstrator stated that the full bed rail order for R5 will be obtained and submitted to LPA via email by POC due date.
Type B
Section Cited
HSC
1569.618(c)(3)
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews, and record review, the licensee did not comply with the section cited above in two out of the two staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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Administrator stated that all staff will be CPR/First aid certified moving forward and will submit certifications for S1 and S2 to LPA via email by POC due 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:Lourdes Montoya
LICENSING EVALUATOR NAME:Jessica Cho
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
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