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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006563
Report Date: 01/17/2025
Date Signed: 01/17/2025 04:25:03 PM

Document Has Been Signed on 01/17/2025 04:25 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:SERENE HAVEN ASSISTED LIVING MISSION VIEJOFACILITY NUMBER:
306006563
ADMINISTRATOR/
DIRECTOR:		DAELTO, VEAHLOUFACILITY TYPE:
740
ADDRESS:26751 VIA GRANDETELEPHONE:
(714) 747-4537
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 5DATE:
01/17/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:21 PM
MET WITH:Airakamil Seleky, caregiverTIME VISIT/
INSPECTION COMPLETED:
04:40 PM
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On this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Nancy Guillen conducted a case management visit to document deficiencies observed during the initial investigation of complaint reference 22-AS-20250113154208 but unrelated to the allegations being investigated.

One resident is observed to be assessed as bedridden in both their individual needs assessment and most recent physician report. The facility has one room identified as bedridden, listed as #2 on the facility sketch, however the bedridden resident is observed in bedroom #6. Type A citation issued, immediate civil penalty assessed.

Additionally, one resident is observed to have a bed with full rails installed. Resident does however not receive hospice care at the time of the visit. Type B citation issued.

As a result of today's observations, two deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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 01/17/2025 04:25 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 01/17/2025 at 03:53 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: SERENE HAVEN ASSISTED LIVING MISSION VIEJO
FACILITY NUMBER: 306006563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2025
Section Cited
CCR
87608(a)(5)(B)

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Per CCR 87608(a)(5)(B) Postural Supports "Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails." This requirement is not met as evidenced by:
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Licensee will replace full rails with half rails and ensure to have adequate physician orders on file. Documentation of both to be provided to LPA before the plan of corrections due date.
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Based on records review and observation, the bed for resident R1 is confirmed to be equipped with full rails. This constitutes a potential risk to the health, safety and personal rights of individuals in care.
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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:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/17/2025 04:25 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 01/17/2025 at 03:58 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: SERENE HAVEN ASSISTED LIVING MISSION VIEJO
FACILITY NUMBER: 306006563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2025
Section Cited
CCR
87606(c)

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Per CCR 87606(c) Care of Bedridden Residents "To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance".
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Licensee stated they would seek to obtain an updated physician report that reflects the resident's current condition and submit documentation in support of an appeal.

Immediate civil penalty assessed.
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This requirement is not met as evidenced by: The resident in bedroom #6 has been assessed to be bedridden per their latest physician report. Bedroom #2 only is cleared for bedridden residents. This constitutes an immediate risk to the health, safety and personal rights of individuals in care.
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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:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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