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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005865
Report Date: 02/12/2025
Date Signed: 02/12/2025 11:57:47 AM

Document Has Been Signed on 02/12/2025 11:57 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:RESPIT MANORFACILITY NUMBER:
306005865
ADMINISTRATOR/
DIRECTOR:		MENDEZ, MARKFACILITY TYPE:
740
ADDRESS:23255 RESPIT AVETELEPHONE:
(949) 460-0317
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 6DATE:
02/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Administrator Mark MendezTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by caregiving staff after explaining the purpose for the visit. Administrator (AD) Mark Mendez was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Mark Mendez submitted a Administrator renewal application to the Administrator Certification Bureau (ACB) on February 2, 2025.

The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six ambulatory, of which five may be non-ambulatory and one may be bedridden, and has a hospice waiver for six. The facility is a single-story home with five resident bedrooms, one of which is shared, three resident bathrooms, one of which is shared, a living room, a dining room, a kitchen, and an attached two car garage. LPA accompanied by the AD conducted a tour of the interior portion of the facility. On today's visit, LPA observed six residents in care, two of which are on hospice, and two caregiving staff present. LPA observed residents relaxing in the living room as well as their respective bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall by the kitchen. LPA inspected the five resident bedrooms, and they were observed to be free of any hazards. LPA observed a fireplace in resident room #1. LPA observed that the fireplace is adequately screened and not in operation at the time of visit. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, and a lamp. All resident beds had clean linens and blankets. LPA observed additional linens are stored in a hallway closet. LPA inspected the three resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars and non-skid floor mats. Faucets and toilets were operational. Hot water temperature measured between 106.7 and 112.4 degrees Fahrenheit.

LPA observed the kitchen has a two day perishable and seven day nonperishable food supply on hand. LPA observed two medications to be stored in the refrigerator. LPA observed kitchen appliances to be clean and operational. The four burner gas stove lights unassisted. CONTINUED ON LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/12/2025
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 4
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: RESPIT MANOR
FACILITY NUMBER: 306005865
VISIT DATE: 02/12/2025
NARRATIVE
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LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed the facility has a three day emergency food and water supply stored in the kitchen. A fire extinguisher is located in the kitchen, and it was observed the be charged and up to date on service. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on February 3, 2025. The centrally stored medication is kept in a locked medicine cart located in a locked closet by the living room. LPA observed a First Aid kit is stored in the closet and it was observed to have all the required components. The door leading to the attached two car garage is kept locked and inaccessible to resident in care. LPA observed the garage is used for storage and laundry.

LPA and AD conducted a tour of the exterior portion of the facility. LPA observed the exterior portion to be clear of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gate on the north side is self-latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed the six resident files. All the required documentation were present and current in the resident files reviewed. LPA reviewed six residents’ medication and medication records. LPA reviewed four staff files. LPA observed that Staff #4 (S4) did not have a Health Screening Report on file. All staff are background cleared and associated to the facility.

Based on today's observations, deficiencies being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Administrator Mark Mendez. A copy of the report and Appeal Rights were provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Brandon Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/12/2025 11:57 AM - It Cannot Be Edited


Created By: Brandon Lopez On 02/12/2025 at 11:40 AM
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: RESPIT MANOR
FACILITY NUMBER: 306005865

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care. During a tour of the interior portion of the facility, LPA observed two medications to be stored in the refridgerator where they can be accessible to residents in care. LPA observed one Subcutaneous injection pen and one insulin glargine injection capsule stored in the refridgerator.
POC Due Date: 02/13/2025
Plan of Correction
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AD discovered an operational lockbox stored in the garage. AD placed the medications in the lockbox and stored it in the refrigerator. POC cleared at time of visit.
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:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/12/2025 11:57 AM - It Cannot Be Edited


Created By: Brandon Lopez On 02/12/2025 at 11:40 AM
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: RESPIT MANOR
FACILITY NUMBER: 306005865

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. During staff file review, LPA observed that Staff #4 did not have a Health Screening Report on file.
POC Due Date: 02/26/2025
Plan of Correction
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AD agreed to get a Health Screening Report for Staff #4. AD agreed to submit the completed Health Screening Report for Staff #4 and submit it to LPA via email or fax by POC 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:Brandon Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2025


LIC809 (FAS) - (06/04)
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