Lake Forest Country Home III

Type of visit: Required - 1 Year

On this date January 30, 2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by facility staff after explaining the purpose for the visit. Licensee Carmen Rivas was present to assist with the inspection.LPA observed that Administrator Diane Antonini has a valid Administrator certificate which expires on May 29, 2026. LPA began a tour of the facility and observed the following. The facility is a single-story home with five resident bedrooms, one staff room, two shared resident bathrooms, a living room, a dining room, a kitchen, and an unattached two car garage. LPA observed four residents in care, none of which are on hospice, and two caregivers present. LPA observed residents in the living room and their bedrooms. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall by the entryway of the facility. LPA inspected the five resident bedrooms, and they were observed to be free of any hazards. LPA observed the resident bedrooms had the required furnishings of a bed, a chair, a chest of drawers, reading lamp, and enough storage space to store personal belongings. All resident beds had clean linens in good repair; meaning no strains or tears. LPA observed additional linens are stored in a hallway closet. LPA inspected the two shared resident bathrooms. Resident bathrooms are clean. Bathrooms are equipped with grab bars, slip resistant floor mats, and shower chairs. Faucets and toilets were operational. Hot water temperature measured between 115.8 and 117.4 degrees Fahrenheit. LPA observed kitchen area to be clean, and free of any mildew and debris. LPA observed the facility to have a two-day perishable and seven-day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed cleaning supplies are stored in a locked kitchen cabinet under the sink. CONTINUED ON LIC809-C LPA observed all smoke detectors and carbon monoxide detectors to be in good repair and operational. LPA observed all fire extinguishers to be fully charged, and up to date. LPA Vanegas observed first aid kit to have all required items such as adhesive tape, scissors, bandages, tweezers, a thermometer, and a first aid manual. LPA conducted a tour of the outside of the facility and observed the following. There is an outdoor shaded seating area, no hazards or objects were observed along the sides of the exit routes. Side doors were unlocked and self latching. LPA Vanegas reviewed four resident files, and two staff files all resident files had all required documents, however two staff files that were reviewed did not have the required training a deficiency was issued on today's date. LPA reviewed medication administration log and medications with licensee, per LPA review no discrepancies were found, and medications are being administered per physicians orders. Based on observations made during today's inspection deficiencies will be issued. An exit interview was conducted with Licensee Carmen Rivas, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 30, 2026

Type of visit: Required - 1 Year

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. Licensee Carmen Rivas was notified via telephone and later arrived to assist with the inspection. LPA observed that Administrator Alan Shelley has a valid Administrator certificate which expires on March 24, 2025. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents with a hospice waiver for two. The facility is a single-story home with five resident bedrooms, one staff room, two shared resident bathrooms, a living room, a dining room, a kitchen, and an unattached two car garage. LPA accompanied by the Licensee conducted a tour of the physical plant. On today's visit, LPA observed six residents in care, none of which are on hospice, and two caregiving staff present. LPA observed residents eating their breakfast in the dining room. LPA observed the See Something, Say Something poster (PUB 475) mounted on a wall by the entryway of the facility. LPA inspected the five resident bedrooms, and they were observed to be free of any hazards. 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 two shared 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 116.7 and 118.9 degrees Fahrenheit. LPA observed the kitchen has a two-day perishable and seven-day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. LPA observed kitchen knives are stored in a locked kitchen cabinet. LPA observed cleaning supplies are stored in a locked kitchen cabinet under the sink. CONTINUED ON LIC809-C A fire extinguisher is located in the kitchen, and it was observed the be charged and serviced as of July 31, 2024. LPA tested the wired smoke detector/carbon monoxide detector which tested operational. LPA observed the facility conducted their last emergency disaster drill on December 15, 2024.The centrally stored medication is kept in a locked cabinet in the kitchen. LPA observed the First Aid kit has all the required components. The unattached two car garage is kept locked and inaccessible to resident. The garage is used for storage and laundry. LPA observed the facility has an emergency food and water supply stored in the garage. LPA and Licensee 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 gates on the northside and southside of the facility are self-latching and can be opened in an evacuation. There are no bodies of water on the premises. LPA reviewed all six resident files. LPA observed that Resident #2 (R2) did not have a Medical Assessment on file. LPA observed that Resident #1 (R1) and Resident #2 (R2) did not have an Admission Agreement on file. LPA reviewed six residents’ medication and medication records. LPA reviewed three staff files. All staff are background cleared and associated to the facility. Based on today's observations, there are deficiencies being cited per Title 22 of the California Code of Regulations. An exit interview was conducted with Licensee Carmen Rivas. A copy of the report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jan 16, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by staff on duty (S1) Melanie Masecampo. S1 Masecampo notified facility administrator (AD) Carmen Rivas about the visit, however AD was unable to be present, therefore, provided consent for S1 Masecampo to receive and sign the report. For today’s visit, LPA observed a total of 6 residents in care and 2 staff members on duty, LPA observed the Administrator's Certificate for facility administrator (AD) Carmen Rivas which expires on 02/16/2024. LPA De Perio toured the interior and exterior portions of the facility with S1 Masecampo. The facility is a single level structure and is licensed for 6 non-ambulatory residents, of which 2 may be on hospice and 0 bedridden. For this visit, there are a total of 6 residents in care. There are a total of 6 bedrooms, of which are 4 private resident rooms, 1 shared resident room and 1 private room for staff. LPA De Perio toured each bedroom in the facility and observed that 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. There are a total of 3 restrooms of which 1 is for staff and 2 are for residents. 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 to be at 110.7 degrees Fahrenheit. 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. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the kitchen. 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. LPA De Perio observed that medications and toxins were locked and inaccessible to residents in care. 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. No bodies of water were observed. For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued. An exit interview was conducted with S1 Masecampo and AD Rivas via phone call. A copy of this report was provided and explained.the state’s words, verbatim · CDSS document, Jan 23, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.