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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006249
Report Date: 02/04/2025
Date Signed: 02/04/2025 05:09:55 PM

Document Has Been Signed on 02/04/2025 05:09 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:OC HOME OF LAGUNA NIGUELFACILITY NUMBER:
306006249
ADMINISTRATOR/
DIRECTOR:		ANGELES, LOIDAFACILITY TYPE:
740
ADDRESS:23962 HILLHURST DRIVETELEPHONE:
(949) 202-8908
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 6DATE:
02/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Loida Angeles, Kristina AdrinedaTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA explained the reason for the visit. The facility is licensed for 6 residents of which 4 can be non-ambulatory and approved for 1 bedridden and a hospice waiver for 3. 6 residents were present during the visit of which 3 are on hospice. Facility is a single story house with 7 bedrooms (1 bedroom is for staff), 5 bathrooms, kitchen/dining room, living room and a 2 car garage that is being used for storage. LPA observed the See Something, Say Something poster (PUB 475) posted next to the front door. LPA and staff toured the facility. LPA observed all resident bedrooms have the required furnishings. LPA observed extra linens stored in the hall closet. LPA observed all the bathrooms are clean and operational. Hot water measured 115.3 to 115.7 degrees Fahrenheit in all bathrooms. LPA observed in bathroom 4 there were cleaning supplies, 409 spray cleaner, Lysol and toilet bowl cleaner under the bathroom sink which was unlocked. Staff removed the items and put them in a locked cabinet during the visit. Smoke detectors and carbon monoxide detectors tested operational. LPA observed the fireplace in the living room is screened and needs a key to operate, the key is kept locked. LPA did not observe any obstacles or trip hazards in the facility. LPA observed the kitchen is clean and operational. Knives are kept locked in a kitchen drawer. Cleaning supplies are kept locked under the kitchen sink. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The fire extinguisher in the dining room is fully charged. LPA and staff toured the garage. The garage is kept locked and used for storage. LPA observed a 3 day emergency supply of food and water in the garage. LPA and staff toured the backyard. No bodies of water observed. There is shaded seating in the backyard to sit outside. Both exit gates are operational. No obstacles or hazards observed in the backyard. During the visit Administrators, Loida Angeles, Kristina Adrineda arrived. LPA reviewed 2 staff files. Both staff members are background cleared and associated to the facility. Both staff members have the required training and CPR training. LPA reviewed 6 resident files and medications. No discrepancies observed.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: OC HOME OF LAGUNA NIGUEL
FACILITY NUMBER: 306006249
VISIT DATE: 02/04/2025
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LPA inspected the first aid kit, the first aid kit has all the required elements. LPA observed there is a laptop for dedicated resident use. There is no verification that facility has conducted an emergency drill in the last 3 months. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report provided along with appeal rights.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/04/2025 05:09 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 02/04/2025 at 04:45 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: OC HOME OF LAGUNA NIGUEL
FACILITY NUMBER: 306006249

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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, 409 spray cleaner, Lysol and toilet bowl cleaner under the bathroom sink which was unlocked which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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Licensee will secure all the cleaning supplies under the bathroom sink so they are not accessible to residents in care.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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, there is no record of the facility conducting an emergency drill in the last 3 months which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/05/2025
Plan of Correction
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Licensee agrees to conduct with staff members on emergency drill on 2/5/2025 and to provide proof to the LPA by the POC due date.
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: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


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