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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005986
Report Date: 12/17/2024
Date Signed: 12/17/2024 02:45:13 PM

Document Has Been Signed on 12/17/2024 02:45 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:ACTIVCARE LAGUNA HILLSFACILITY NUMBER:
306005986
ADMINISTRATOR/
DIRECTOR:		MILLER, PATRICIAFACILITY TYPE:
740
ADDRESS:25200 PASEO DE ALICIATELEPHONE:
(858) 565-4424
CITY:LAGUNA HILLSSTATE: CAZIP CODE:
92653
CAPACITY: 72CENSUS: 52DATE:
12/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:47 AM
MET WITH:Patricia MillerTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by receptionist. LPA met with Patricia Miller, Executive Director and LPA explained the nature of the visit. Facility is licensed for 72 non-ambulatory residents, of which 17 may be bedridden. Facility has an approved hospice waiver for 15 residents. There are 12 residents currently on hospice during today's visit. This facility consists of a memory care unit which are protected by delayed egress exits.

LPA Martinez along with Executive Director toured the inside and outside of the physical plant of the memory care unit. LPA observed three dining halls for residents. LPA observed menus mounted on the wall and the food offered is varied and healthful with an everyday optional menu. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Maintenance records were observed in the main kitchen. During the tour LPA observed residents having lunch in all the three dining areas. LPA inspected that medication is centrally stored in a safe locked location; facility has a medication room. LPA observed and inspected medication carts that are used to dispense meds to residents and observed medication was labeled and stored inaccessible to residents in care. Facility has 4 bedroom wings and resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Resident bathrooms were tested for water temperature and water temperature measured between 105.5 and 107.7 degrees F in tested bathrooms. Facility has common showers and bedrooms have a full bathroom or half bathroom in each room. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPA observed several residents who appeared clean, and happy. LPA observed that toxic chemicals, cleaning solutions and

Continued on LIC809-C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2024
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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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: ACTIVCARE LAGUNA HILLS
FACILITY NUMBER: 306005986
VISIT DATE: 12/17/2024
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disinfectants are stored locked in a locked storage closet of each wing of the bedrooms. LPA observed a posted activity schedule for memory care residents. LPA observed residents in the memory care unit with care staff present. LPA observed and verified the delayed egress exits in all the patios of the facility. Fire extinguishers are fully charged and had a service date of February 19, 2024, and were observed to be mounted throughout the facility. LPA verified that smoke detectors were serviced, and last service date was January 22, 2024, and are tested annually. Sprinkler systems are tested every 5 years and last service date was August of 2021. Both are serviced and tested by an outside vendor of First Choice Fire Protection. LPA reviewed testing documentation and observed facility to have services logs. Emergency drills are being conducted monthly with the last drill conducted on November 18, 2024. Outside grounds have ample shaded seating for residents. LPA reviewed six resident files and six staff files. All resident files contained required documentation including updated physician reports and care plans. Staff files contained required documentation including health screens, first aid, and fingerprint clearance.

Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.



This report was reviewed with the Executive Director and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2024
LIC809 (FAS) - (06/04)
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