Lake Forest Country Home #2

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Garlli Tat and Celine Rodriguez conducted an unannounced visit for the Required 1 Year Inspection. LPAs explained the purpose of today’s visit, and were greeted and granted entry by staff on duty (S1) Carmen Rivas, who also notified facility administrator (AD) Paul Smith about visit. For today’s visit, LPAs observed a total of five residents in care and three staff members on duty, of which current staff are background cleared and associated. LPAs observed the Administrator's Certificate for Paul Smith which expires on June 17, 2026. LPAs observed the PUB475 "See Something Say Something" poster located in the hallway. LPAs toured the interior and exterior portions of the facility with S1. The facility is a one-story structure and is licensed for six non-ambulatory residents, of which three may be on hospice and zero bedridden. There are a total of six bedrooms, of which 1 is a shared resident room, 4 private resident rooms, and 1 is a bedroom for staff. LPAs 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 detectors and auditory exit alarms were tested and operational. There are a total of five bathrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were observed. Water temperature was tested to be 105 degrees Fahrenheit. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged and located in the kitchen. Fire extinguisher tagged and dated for February 2025. LPAs observed the emergency disaster and evacuation plan which is located by kitchen/dining room. Facility had back-up emergency food and water supply. LPAs observed that First Aid Kit had all the required components, including tweezers, scissors, and the First Aid Handbook. LPAs observed that medications and toxins were locked and inaccessible to residents in care. For the exterior portion, LPAs observed a shaded area, patio furniture, and the grounds were free of any hazards. There are two gates in the backyard, which both are self-closing, self-latching, and were equipped with alarms. No bodies of water were observed. LPAs reviewed five resident and two staff files. LPAs interviewed residents and staff present. For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with S1. A copy of this report was provided and explained the time of exit.the state’s words, verbatim · CDSS document, Aug 26, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Alvaro Ramirez, Jr. and Samer Haddadin conducted an unannounced visit for the Required 1 Year Inspection. LPAs explained the purpose of today’s visit, and were greeted and granted entry by Caregiver Rosdiana Sitanggang. Administrator (AD) Carmen Rivas arrived shortly after. For today’s visit, LPAs observed a total of five residents in care and two staff members on duty. LPAs observed the Administrator's Certificate for facility AD Carmen Rivas which expired on February 2022; a Deficiency was issued today. LPAs toured the interior and exterior portions of the facility with Caregiver Sitanggang. The facility is a one-story structure and is licensed for six non-ambulatory residents, of which three may be on hospice and zero bedridden. There are a total of six bedrooms, of which five are resident bedrooms, and one is a bedroom for staff. LPAs 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 three full restrooms and one half restroom. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 108.5-112.8 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 and located by the kitchen. During today's visit LPAs observed resident having a tuna sandwich, chicken soup, fruit and juice for lunch. CONTINUED ON LIC809-C... LPAs observed the emergency disaster and evacuation plan which is located by kitchen/dining room. Facility had back-up emergency food and water supply. LPAs observed that First Aid Kit had all the required components. LPAs observed that medications and toxins were locked and inaccessible to residents in care. For the exterior portion, LPAs observed a shaded area, patio furniture, and the grounds were free of any hazards. There are two gates in the backyard, which both are self-closing and self-latching. No bodies of water were observed. LPAs reviewed five resident and three staff files. LPAs interviewed residents and staff present. For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. LPAs advised AD Rivas to use the general email address: CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA. An exit interview was conducted with AD Rivas. A copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, Sep 27, 2024