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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004323
Report Date: 10/03/2022
Date Signed: 10/03/2022 04:47:57 PM

Document Has Been Signed on 10/03/2022 04:47 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:MEISON LA PAZ IFACILITY NUMBER:
306004323
ADMINISTRATOR:SAKVADOR DIAZ JRFACILITY TYPE:
740
ADDRESS:25421 MARINA CIRCLETELEPHONE:
(949) 859-5049
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: DATE:
10/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jennifer Perez, Administrator (via phone)TIME COMPLETED:
05:00 PM
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On 10/03/2022 at 3:00pm, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility in order to conduct a required annual inspection mostly focusing on Infection Control procedures. LPA was greeted and granted entry by caregivers after undergoing the COVID-19 screening procedure and explaining the purpose of the visit. Administrator Jennifer Perez was notified by phone. Administrator couldn't assist with the visit as they had a previously scheduled appointment to attend. LPA agreed to go over the report with the administrator prior to having a facility representative sign it.

At approximately 3:30pm, LPA accompanied by caregivers toured the physical plant of the facility. There are currently four (4) residents in care, one of which is receiving hospice care. Residents are observed relaxing in their respective bedrooms. All appear clean and well taken care of. The three (3) shared bedrooms include all necessary components of furnishing. Bathrooms are equipped with grab bars and slip mats. Facility is clean, sanitary and free of odors in all areas inspected. An ample supply of linen is observed.

Sharp instruments are kept in a kitchen drawer equipped with a functioning magnetic lock. Cleaning supplies are located in a kitchen cabinet under the sink, also equipped with a functioning magnetic lock. Additional cleaning supplies and detergents are located in the attached garage, which is secured with a combination doorknob. The centrally stored medication is located in a locked closet near the dining room.

LPA observed a sufficient supply of food and water present. The facility has COVID-19 Precautions posters and all required department postings along with hand washing signs. The fire extinguisher present is charged. The maintenance tag attached to it shows a maintenance date of November 2020, which means that the maintenance is out of date by almost two years at the time of the visit. Staff present is adequately cleared and associated in Guardian.

CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MEISON LA PAZ I
FACILITY NUMBER: 306004323
VISIT DATE: 10/03/2022
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CONTINUED FROM FORM LIC809

LPA and caregiver toured the outside of the facility and observed it to be free of obstructions. Outdoor furniture and a shaded area are present in the backyard for the enjoyment of residents and visitors. The entrance gates on both sides of the house are self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises.

Based on the observations made during today’s visit, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with facility representative and a copy of this report along with appeal rights was provided and left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2022 04:47 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 10/03/2022 at 04:02 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: MEISON LA PAZ I
FACILITY NUMBER: 306004323

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
6151(e)(3)
The California Code of Regulations Title 7 Section 6151(e)(3) indicates that: "Portable fire extinguishers shall be subjected to an annual maintenance check. "

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, fire extinguisher maintenance is out of date since November 2021 which poses a potential Health, Safety, or Personal Rights risk to persons in care.
POC Due Date: 10/17/2022
Plan of Correction
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Licensee will contract a licensed vendor to performed the required annual maintenance on the fire extinguishers present within the physical plant and provide documentation thereof to Licensing Program Analyst before the Plan of Corrections 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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
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