Lake Forest Country Home #2

Type of visit: POC

Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC 809D on 08/04/2022. NOTE: POC date was extended to 8/25/22. LPA De Perio explained reason for visit and was greeted and granted entry by facility administrator (AD) Carmen Rivas. For today's visit, LPA De Perio verified that there are currently 4 residents in care, of which 1 is on hospice and there are 2 staff members on duty. On 08/04/22, LPA De Perio observed that there was no Administrator Certificate posted, along with conducting an interview with facility administrator via phone who stated that certificate expired in February 2022, and stated that no renewal fee has been submitted. *Deficiency cited under Title 22 Regulation 87407(e) pertaining to Administrator Certification Requirements has been CLEARED. Licensee has submitted and provided documentation indicating that the following have been completed: (1) A completed Application for Administrator Certification form LIC 9214 (2) Evidence of completion of the required continuing education hours as specified in section 87407(a) or 87407(g), if applicable. The total number of hours required to complete if they had remained certified. The date of computation shall be the date application for renewal is received by the Department's Administrator Certification Section. (3) Payment of a non-refundable delinquency fee equal to three times the one hundred dollar ($100) renewal fee, or three hundred dollars ($300). (4) A copy of the front and back of his/her current nursing home wallet license, or equivalent, if the applicant is a current Nursing Home Administrator. Licensee has complied with the terms of the POC. LPA De Perio conducted an exit interview with AD Rivas and a copy of this report and Letter of Cleared Deficiency has been provided to the facility.the state’s words, verbatim · CDSS document, Sep 1, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 2 staff were on duty, who contacted facility administrator (AD) Carmen Rivas about visit. AD Rivas provided consent for staff on duty (S1) Elizabeth Ferrer to conduct tour, sign and receive report, due to AD Rivas being unavailable and having to attend a medical appointment. As of 8/2/22, there are no active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted in the hallway of the facility. The PUB475 "See Something, Say Something" poster was also observed to be located in the hallway. LPA De Perio toured the interior and exterior portions of the facility with S1. The facility is a single level structure and is licensed for 6 non-ambulatory residents, 0 bedridden and 2 hospice . Currently, there are a total of 4 residents in care, of which 1 is on hospice. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured at 106.4 degrees Fahrenheit and hand washing signs were also posted in each restroom. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the kitchen. For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which both were self-closing and self-latching. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the hallway of the facility. Facility had back-up emergency food and water supply, located in the garage. LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in the living room. Medications were locked and located in a kitchen cabinet. Toxins were also observed to be locked and inaccessible to residents. LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with S1. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. LPA De Perio advised S1 and AD Rivas to use the general email address: CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA. LPA De Perio conducted an exit interview with S1 and AD Rivas via phone call and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 4, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Celine De Perio conducted a continuation of the Case Management visit which took place on 6/28/22. During today's visit, 2 staff were on duty, who contacted facility administrator (AD) Carmen Rivas about visit. AD Rivas was unavailable but provided consent for staff on duty (S1) to receive and sign report. LPA De Perio also obtained a copy of the Sheriff's report submitted by AD Rivas and reviewed the necessary documents. During this visit, LPA De Perio initiated an interview with resident (R1) to discuss about the incident that took place. R1 stated “I put a stop on the payment of the check, but Sherri told me she ripped it up and did not process it and I believe her.” R1 also informed LPA De Perio that she has checked her bank account and there were no indications that the check was ever processed. After file reviews, interviews and proof that the check has not been processed, this incident has been resolved. There were no deficiencies issued during this Case Management visit. No citation was issued during this visit. An exit interview was conducted with Licensee/Administrator Carmen Rivas via phone, and S1 and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Aug 4, 2022

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to Lake Forest Country Home #2 to conduct a case management (CM) visit. The purpose of this CM visit was to gather facility files in regards to the incident reported by facility administrator (AD) Carmen Rivas. LPA De Perio arrived at facility at 10:14 AM and was granted entry by staff on duty. LPA observed a total of 4 residents in care. LPA toured the interior portions of the facility with staff and resident. AD arrived at 10:33 AM and provided LPA copies of the following documents: SOC 341 (completed and provided LPA hard copy) Admission Agreement Resident file Staff file Emergency contact for resident Staff training Resident roster Personnel report Employee rights Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders Criminal Record Statement Appraisal/Needs and Services Plan Personal Possession Liability Release LIC 602 Copy of written check provided by resident LPA De Perio conducted interviews and file reviews during visit. Due to time constrains, this case management visit will be completed at a later time. There were no deficiencies issued during this Case Management visit. No citation was issued during this visit. An exit interview was conducted with Licensee/Administrator Carmen Rivas and a copy of this report was provided at the time of this visit.the state’s words, verbatim · CDSS document, Jun 28, 2022

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by caregiver and explained the nature of the visit. LPA Martinez toured the inside and outside of facility. There are three residents in care and there are no active covid-19 cases. LPA observed one resident in dinning room, one resident in living room watching television and one resident in their bedroom. All residents appeared to be clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA inspected residents’ bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA observed a check in station in the main entry of the facility. Facility is taking temperatures daily and documenting results. LPA observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. LPA toured the outside of the facility and observed two seating areas for resident’s enjoyment. Facility has completed the LIC808 Mitigation plan and LPA approved the plan on today’s visit. Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Administrator and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Sep 15, 2021