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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004588
Report Date: 07/15/2022
Date Signed: 07/15/2022 11:34:13 AM

Document Has Been Signed on 07/15/2022 11:34 AM - 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:CARING SISTERS HOME AND GARDEN @ LAKE FORESTFACILITY NUMBER:
306004588
ADMINISTRATOR:ESTHER CORTEZ REYFACILITY TYPE:
740
ADDRESS:23191 LA VACA STREETTELEPHONE:
(949) 613-1114
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 5DATE:
07/15/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Administrator - Esther ReyTIME COMPLETED:
11:57 AM
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit for the purpose of a Plan of Correction (POC) visit, based on the deficiency cited in LIC form 809D on 06/28/2022. LPA De Perio was greeted and granted entry into the facility by Administrator Esther Rey and explained the reason for the visit.

On 7/7/2022, AD failed to correct the following:
Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to Inaccessible Items (Care of Persons with Dementia)

As of 7/15/2022, Deficiency cited under Title 22 Regulation 87705(f)(2) pertaining to Inaccessible Items (Care of Persons with Dementia) has been CLEARED.
Licensee has secured the following items: vitamins and disinfectant supplies.
LPA De Perio observed vitamins, and disinfectant items locked and inaccessible to residents in care.
Licensee has complied with the terms of the POC.

Per 7/7/2022 visit, it was requested for AD to provide an updated LIC 500 to LPA by 07/14/2022. This has been COMPLETED and also provided during visit.

LPA De Perio conducted an exit interview with AD Rey and a copy of this report and Letter of Cleared Deficiency has been provided to the facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2022
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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