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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004588
Report Date: 07/10/2024
Date Signed: 07/10/2024 05:57:47 PM

Document Has Been Signed on 07/10/2024 05:57 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:CARING SISTERS HOME AND GARDEN @ LAKE FORESTFACILITY NUMBER:
306004588
ADMINISTRATOR/
DIRECTOR:
ESTHER CORTEZ REYFACILITY TYPE:
740
ADDRESS:23191 LA VACA STREETTELEPHONE:
(949) 613-1114
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 5DATE:
07/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:06 PM
MET WITH:Esther ReyTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Esther Rey and explained the reason for the visit. LPA and the Administrator toured the facility. LPA observed and measured the See Something, Say Something poster (PUB 475) and it measured 14 1/2 by 22 inches. LPA observed the living room fireplace is screened. The living room has couches and chairs for residents or visitors to sit. There is a large screen TV mounted above the fireplace. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The fire extinguisher in the kitchen is fully charged. LPA observed medications are kept locked in a cart in the kitchen. LPA observed knives are kept locked in a kitchen cabinet. LPA and the Administrator toured the facility. LPA observed all resident bedrooms had the required furnishings and bed linens. Smoke detectors/Carbon monoxide detectors tested operational. The facility has two stories. The second floor is for staff only and no residents live on the second floor. LPA did not observe an evacuation chair. The garage is used for storage and kept locked. Hot water measured 113.0 degrees Fahrenheit to 116.9 degrees Fahrenheit in the 2 bathrooms downstairs. During the visit the facility had multiple AC units running to keep the facility temperature at 79.0 degrees Fahrenheit. LPA and the Administrator toured the backyard. LPA observed a tortoise, a dog, 6 birds in 3 cages and 2 chickens in a chicken coupe in the backyard. LPA observed old bed rails, bikes, ladders and plants on each side of the house leading to the exit gates. The items obstructed the path to both exit gates. Both exit gates are operational. No bodies of water observed in the backyard. There is a table with an umbrella and chairs for residents to sit outside. LPA observed a shed in the backyard. The shed is kept locked and used for storage. There is a covered patio in the backyard which has exercise equipment. LPA reviewed 5 resident files and 5 resident medications. LPA observed Resident 1 (R1) only had 2 out 5 of their prescribed medications on hand in the facility that were listed on their medication administration record (MAR) for July 2024. LPA reviewed 4 staff files, no discrepancies observed. LPA inspected the first aid kit, the first aid kit has all the required elements. Deficiencies are being cited per title 22 Division 6 of the California Code of Regulations on the attached LIC 809D. An exit interview was conducted with the Administrator and a copy of the report provided along with appeal rights.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
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 07/10/2024 05:57 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 07/10/2024 at 05:21 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: CARING SISTERS HOME AND GARDEN @ LAKE FOREST

FACILITY NUMBER: 306004588

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(16)
Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To receive or reject medical care or other services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a record review and observation, R1 did not receive all of their medication because the facility only had 2 out 5 of their prescribed medications which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/11/2024
Plan of Correction
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Licensee agrees to have all of R1's prescriptions filled and on hand at the facility for R1's use. Licensee agrees to always have all residents prescribed medication on hand for their use. Licensee to submit proof to LPA by the 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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/10/2024 05:57 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 07/10/2024 at 05:35 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: CARING SISTERS HOME AND GARDEN @ LAKE FOREST

FACILITY NUMBER: 306004588

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA observed old bed rails, bikes, ladders and plants on each side of the house leading to the exit gates. The items obstructed the path to both exit gates. 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.
POC Due Date: 07/22/2024
Plan of Correction
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Licensee agrees to clear the passageways to both exits so no items obstruct it. Licensee to submit proof to LPA 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:Sheila Santos
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024


LIC809 (FAS) - (06/04)
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