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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004769
Report Date: 08/16/2024
Date Signed: 08/16/2024 09:21:29 AM

Document Has Been Signed on 08/16/2024 09:21 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SEASONS AT LAGUNA - 3FACILITY NUMBER:
306004769
ADMINISTRATOR/
DIRECTOR:		MARICEL GUIBILONDOFACILITY TYPE:
740
ADDRESS:26291 AVENIDA CALIDADTELEPHONE:
(949) 482-7412
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
08/16/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator/Licensee Maricel N. GuibilondoTIME VISIT/
INSPECTION COMPLETED:
09:25 AM
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced Annual Continuation inspection. LPA was greeted and allowed entry into the facility by care giver Joy Recio to whom LPA discussed the purpose of the visit. Later, Administrator/Licensee Maricel N. Guibilondo joined the visit. According to the facility’s license, the facility has a maximum capacity of six (6) non-ambulatory clients, of which five (5) can be bedridden. Facility also has a hospice waiver for 5.


LPA, accompanied Licensee/Administrator Maricel N. Guibilondo , to continue the tour of the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility’s ambient internal temperature was compliant. Hot water temperature at taps accessible to clients were all compliant. No pools or bodies of water on the premises.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients.

LPA also conducted an inspection of the centrally stored medications today. They were properly stored and locked in medication room. Medication logs and medications reviewed were current and medications appear to be administered according to the label instructions.

[Continued on 809-C]

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: SEASONS AT LAGUNA - 3
FACILITY NUMBER: 306004769
VISIT DATE: 08/16/2024
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[Continued form 809]

LPA conducted further interviews and per Administrator/Licensee Maricel N. Guibilondo, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit was complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA reviewed the theft and loss policy and procedures. Transportation procedures are compliant. LPA interviewed staff members and residents during the initial inspection on 8/9/2024 . LPA interviews did not raise any licensing concerns. Staff and resident records reviewed on 8/9/2024 verified that all staff and residents records are complete and compliant. Licensee presented proof of current liability insurance. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. Administrator’s certification is current.



No deficiencies were observed or cited at the time of visit.

An exit interview was conducted with Licensee/Administrator Maricel N. Guibilondo, to whom copies of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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