Casa Del Lago

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of conducting the Required 1-Year annual evaluation using the CARE Inspection Tool. LPA was greeted and granted entry by Caregiver Veronica Gastelum after introducing self and stating the reason for the visit. Administrator (Admin) Lourdes Rivero arrived on premise shortly after to assist with the inspection. Admin has a valid certificate expiring on July 30, 2026. The following was observed during the inspection: This is a single story property located in a residential neighborhood comprised of four resident bedrooms and three resident bathrooms. Facility operates within the conditions and limitations specified on the license. There are six residents in care, five of which are receiving hospice services. LPA along with Caregiver Gastelum toured the interior portion of the facility. The facility is clean and in good repair. All common areas were inspected including the attached two car garage. LPA inspected all resident bedrooms. The resident bedrooms' were appropriately furnished, beds and bedding supplies were in good condition, adequate lighting was provided, and sufficient storage space for each residents' personal belongings were observed. All bathrooms were found be in compliance, clean, and operational. Slip resistant mats were available. The hot water temperature in the bathrooms measured at 115.0, 120.0, and 119.0 degrees Fahrenheit. Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. The exit gates are operational, and there were sufficient seating and shading in the patio area. There are no bodies of water on premise. The first aid kit contains all necessary elements. The fire extinguishers were mounted, charged, and serviced on April 21, 2025. The auditory devices and dual functioning smoke/carbon monoxide detectors were tested and operational. Facility maintains emergency food and water. Disaster supplies noted on the emergency disaster plan were not available. The facility land line number, (949) 716-4497, was tested and remains available. Complaint Poster, 'See Something, Say Something,' (PUB 475) was available, however was posted in the incorrect size of 12"x18." LPA reviewed six of six resident and two personnel files in which no discrepancies were found. Medications were audited for three out of six residents. No discrepancies were found with medication administration and documentation. Admin and staff were reminded to document timely. Present staff are background cleared and associated to the facility. Staff training is up-to-date. Disaster drills are not conducted quarterly as last known drill per log was conducted on February 23, 2025 at 2pm. LPA consulted on the following: to ensure the PUB475 meets the Department's size requirement of 20"x26," to ensure staff are completing the Medication Administration Record (MAR) timely, to conduct quarterly drills accounting various emergency scenarios, to ensure that the emergency disaster plan is reviewed annually and updated as necessary on page 9, and to ensure that the disaster supplies are obtained as reflected on the plan. Based on the observations made during today's visit, no deficiencies are being cited. Advisory notes are being issued. An exit interview was conducted with Administrator Lourdes Rivero, and a copy of this report was provided at exit.the state’s words, verbatim · CDSS document, Mar 10, 2026

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose of conducting the Required 1-Year annual evaluation using the Care Inspection Tool. LPA was greeted and granted entry by Caregiver Azalia Ayala and explained the reason for the visit. Administrator (Admin) Lourdes Rivero arrived on premise to assist with the inspection. Administrator Rivero has a valid administrator's certificate expiring on July 30, 2026. The facility is a single story structure and is licensed to operate for six non-ambulatory residents and has a hospice waiver for two residents. Based on observation, there are two staff on duty caring for six residents of which three are in hospice care. It is determined that facility is operating beyond the conditions and limitations specified on the license by exceeding the number of hospice residents that can be accepted at one time. During the walk through, LPA observed four resident bedrooms and two and a half resident bathrooms. Resident bedrooms had all required furnishings. LPA observed the following issues in the bedrooms: Resident #5 (R5) did not have a bed rail order and the window screen in the bedroom of Resident #4 (R4) has a tear that needs to be repaired. Bathrooms were found to be in compliance, clean, and operational. The hot water temperature measured at 109.4, 107.0, and 107.7 degrees Fahrenheit. All common areas were inspected including the attached two car garage. LPA observed sufficient emergency food and water in the garage. LPA did not observe a generator and/or emergency lights as indicated on the Emergency Disaster Plan (LIC 610D). Toxins, disinfectants, sharps, and medications were secured and inaccessible. LPA observed sufficient two-day supply of perishables and seven-day supply of non-perishable food available in the kitchen and garage. LPA toured the exterior portion of the facility. The outdoor passageway is free of obstruction. Both exit gates were self-closing and self-latching. LPA observed sufficient seating and shading. The fire extinguisher was charged, mounted, and serviced on April 22, 2024. The auditory devices dual functioning smoke/carbon monoxide detectors were tested and operational. The auditory device in the master bedroom sliding door was not operable. Emergency evacuation drills are conducted quarterly. Last known drill was conducted on February 23, 2025 at 2:00pm per review of the log. The first aid kit contains all necessary elements. The facility land line number, (949) 716-4497, was tested and remains available. The liability insurance is valid expiring on March 12, 2025. Complaint Poster, 'See Something, Say Something,' (PUB 475) was available and posted in the incorrect size of 8.5"x11." LPA conducted a file review of all residents and two staff. Discrepancies noted with staff files. Two out of the two staff did not posses a CPR/First Aid Training certificate. Medications were audited. No concerns. Interviews were conducted. The following items were addressed during the exit interview: to post the license and Complaint Poster (PUB 475) in the correct size, to repair the window screen tear in R4's bedroom, replace the battery for the auditory device on the sliding door of the master bedroom, cover the exposed wire in the ceiling of the hallway, amend the LIC610D as well as complete page 9, conduct quarterly drills of various emergency scenarios per shift, obtain a full bed rail order for R5, ensure at least one staff on duty per shift possesses a CPR/First aid certificate, to submit a hospice waiver to the Department requesting an increase in hospice as the facility is currently approved to accept two hospice residents, and to pay the annual dues due on March 30, 2025. Based on the observations made during today's visit, deficiencies are being cited. Advisory Notes (LIC9102s) are also being issued. An exit interview was conducted with Administrator Lourdes Rivero, and a copy of this report (LIC809/LIC809-C), LIC809-Ds, LIC9102s, LIC811s, appeal rights, and a copy of the regulation Hospice Care Waiver 87632 were provided at the end of the visit.the state’s words, verbatim · CDSS document, Mar 5, 2025

The state marks this report as 8 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose to conduct the Required 1-Year Annual Inspection. LPA was greeted and granted entry after stating the purpose of the visit to Caregiver Veronica Gastelum. Administrator (Admin) Lourdes Rivero was not present to assist with the facility inspection on today's date. LPA spoke to the Admin by telephone and consented Caregiver Martinez to sign the report on her behalf. LPA conducted a tour of the physical plant accompanied by Caregiver Martinez, and the following was observed: This is a single story facility comprised of four resident bedrooms and three resident bathrooms, laundry room, living/family room, dining room, and a two-car garage. LPA toured the outside grounds. There was shading and sufficient seating for the residents. The exit gates were self-closing and self-latching. LPA observed three residents and two caregivers on duty. The resident bedrooms are spacious and easily accommodates the residents' furnishings. Furniture for each resident bedrooms were inspected. The bathrooms were clean, faucets, toilets, and grab bars were operational. The hot water temperature initially measured at 133.7 in the private bathroom, 131.5, and 127.4 degrees Fahrenheit in the shared bathroom. The water heater was readjusted and corrected during the visit which then measured at 117.6, 116.2, and 118.9 degrees Fahrenheit. There were sufficient supply of clean linens. LPA observed a two-day supply of perishables and a seven-day supply of non-perishable food as required per egulation. Carbon monoxide, smoke detectors, and the auditory devices were tested and operational except in Bedroom #1. Caregiver Martinez was unable to reach and test the two smoke detectors located in the hallway by the entrance and in the master bedroom. The fire extinguishers were serviced on 04/07/23. Medications and sharps were locked and inaccessible to the residents. Toxins in the laundry room and under the sink were not secured at the time of inspection. Facility had ample supply of emergency supplies including food/water. LPA reviewed three out of the three resident files and two out of the two staff files including the resident medications. LPA is reminding the following: Licensee to pay the licensing fees due on 03/30/2024, to ensure at least one staff on duty with a CPR/First Aid training is on premise at all times, to submit a recording of the testing of the (2) smoke detectors, to repair/replace the smoke detector in Bedroom #1, to replace (1) magnetic lock to the left sink cabinet, to ensure the laundry room is locked at all times, to complete the missing sections of the LIC610E (Emergency and Disaster Plan), to notify the Department designating a facility representative during the administrator's absence, to accurately document when the medication was refused on the Medication Administration Record (MAR), and to dispense the medications matching the corresponding date. Based on the observations made during today's visit, a deficiency is being cited as per the Title 22 Division 6 Chapter 2 of the California Code of Regulations. Advisory Notes (LIC9102s) were also issued during the visit. An exit interview was conducted with Caregivers Ana Maria Martinez and Veronica Gastelum, and a copy of this report including the LIC809C, and the LIC9102ss were provided at the end of this visit.the state’s words, verbatim · CDSS document, Jan 31, 2024

The state marks this report as 13 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.