Watermark Laguna Niguel

Allegation investigated: Staff did not ensure resident' medical needs were being met resulting in resident developing an infection Staff did not seek medical attention to resident

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with Executive Director Johnny Ortiz and explained the reason for the visit. The investigation into the allegation, staff did not ensure resident's medical needs were being met resulting in resident developing an infection, revealed the following. It was reported that after Resident 1 (R1) cut their leg and returned to the facility staff did not provide proper care and R1 developed an infection. R1 suffered an injury to their leg on February 21, 2026. Staff 1 (S1) reported that the injury was discovered around 5:50 am and the resident reported that it happened earlier in the morning and they didn’t press their pendant for assistance. S1 called 911 and resident was transported to the hospital. Facility staff notified R1’s responsible party and their physician. R1 came back to the facility the same day with 12 stitches (staples) to close the injury to their leg. Unsubstantiated R1 where abouts are unknown so they couldn't be reached for an interview. R1’s statement of account ledger shows R1’s responsible party was issued a refund. The evidence gathered refutes the allegation therefore the allegation is deemed unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of the report was provided. The Administrator, S1 and Staff 2 (S2) reported that R1’s responsible party never provided the hospital discharge paperwork for R1. The Administrator reported they ordered a palliative care visit from a Hospice company to have R1 and their injury evaluated. R1’s responsible party did not respond to requests for an interview. A review of R1’s records does not show R1 was ever diagnosed with an infection. R1’s care visit shows only one visit was completed on February 23, 2026, and no issues were noted. R1 was moved out of the facility on February 28, 2026. R1’s location is unknown, so they were not interviewed. R1 was injured and as soon as the facility discovered the injury 911 was called and R1 was taken to the hospital and treated. Upon R1’s return, facility staff scheduled a follow-up visit with a medical provider. R1’s records do not show any mention of an infection. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, staff did not seek medical attention to resident, revealed the following. It was reported that after R1 was injured staff did not get R1 medical attention. R1 suffered an injury on February 21, 2026. According to the special incident report (SIR) submitted by the facility to the Agency (Community Care Licensing) on February 25, 2026, R1 was discovered by staff at 5:50 am with a cut on their leg. Staff called 911 and R1 was transported to the hospital and treated. Staff notified R1’s responsible party and their physician. It was reported that staff did not seek medical treatment for R1. S1 and S2 who were present when R1’s injury was discovered reported that R1’s injury was discovered during a routine check at 5:50 am. S1 reported that R1 told them they had injured themselves earlier but did not report the accident. S1 and S2 stated that they called 911 as soon as possible after seeing the injury. R1’s where abouts are unknown so they could not be interviewed. R1’s responsible party did not respond to requests for an interview. The Administrator, S1 and S2, reported that R1’s responsible party did not provide the hospital discharge paperwork for R1 and R1's responsible party brought R1 back to the facility after their hospital visit. Based on the evidence gathered the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Sep 24, 2026 · control 22-AS-20260603152802

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with the Executive Director Johnny Ortiz and explained the reason for the visit. The Executive Director's Administrator's Certificate expires on March 15, 2028. Facility is licensed for 55 ambulatory and 68 non-ambulatory (Total capacity 135) of which 12 may be bedridden (1st floor only) and a hospice waiver for 25. Facility is one building with 3 floors and underground parking. There is a central for courtyard with a fence in the middle, one side if for memory care, one side is for assisted living, with shaded seating areas for residents to sit outside. LPA and the staff toured the facility. Memory care is located on the first floor. Assisted living is located on the second and third floors. LPA observed the See Something Say Something poster (PUB 475) posted in the main entry way of the facility. LPA toured the memory care unit. LPA observed all resident rooms had the required furnishings and bed linens. LPA tested the delayed egress exits in memory care. All the delayed egress exits in memory care are operational. Each floor has it's own medication office. LPA observed that each medication office on each floor is kept locked and medications are stored in a medication cart in the locked office. LPA inspected each first aid kit and all 3 had the required items. LPA inspected 8 resident rooms, 3 on the third floor, 3 on the second floor and 2 on the first floor. LPA observed the 8 resident rooms had the required furnishings and bed linens. Hot water measured 110.6 to 113.0 degrees Fahrenheit in the resident rooms. Each room has it's own smoke detector. All smoke detectors in the rooms inspected tested operational. The dining room and kitchen are on the second floor. LPA observed a fitness area on the second floor. LPA toured the kitchen. LPA observed the kitchen is clean and organized. LPA observed a two day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed a 3 day emergency supply of food and water stored in a storage room across from the kitchen. The refrigerator and freezer temperatures are tracked using a temperature log. LPA observed the refrigerator temperature was 38.0 degrees Fahrenheit and the freezer was - 2.0 degrees Fahrenheit. LPA observed the fire extinguishers throughout the facility are fully charged. The facility has four stairways. Each stairway has an emergency evacuation chair. The carbon monoxide detector in the kitchen is operational. The last emergency drill was conducted on July 21, 2026. LPA observed each floor has an activity area with a TV, books, games and an area to sit. LPA toured the central outdoor courtyard. There is one courtyard area for memory care with shaded seating to sit outside. No bodies of water observed. The outdoor courtyard for assisted living has a fountain. There is shaded seating to sit outside. No obstacles or hazards observed in either courtyard. LPA reviewed 4 staff (caregivers) files. 2 of the 4 staff members had a valid CPR/First-Aid card. All 4 staff members had 20 hours of training but no documented training for, 4 hours of training specific to postural supports, restricted health conditions and hospice care. All staff members encountered and the staff members whose files were reviewed are background cleared and associated to the facility. LPA reviewed 7 resident files and medications. No discrepancies observed. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations (CCR). An exit interview was conducted and a copy of the report provided along with appeal rights.the state’s words, verbatim · CDSS document, Aug 12, 2026

Allegation investigated: Staff did not ensure that resident took medication as prescribed

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings for the complaint investigation into the allegation listed above. LPA met with Executive Director Johnny Ortiz and explained the reason for the visit. The investigation into the allegation, staff did not ensure that the resident took medication as prescribed revealed the following. It was reported that Resident 1 (R1) did not take their prescribed medication for 12 days. A review records shows R1 moved into the facility on February 28, 2024 and moved out on April 2, 2024. A review of R1's Medication Administration Record (MAR) for February, March and April, 2024 shows R1 was prescribed 10 medications including 2 PRNs. R1 missed routine medications on March 4, because they were out of the facility with their family. On March 8, 2024 R1 missed routine medications, Ezetimbe, Losartan potassium F/C, Quetiapine Fumarate and Isosorbide Mononitrate ER for their 9:00 am medication pass. Staff reported that after any missed dose the physician and responsible party are notified. Based on the evidence gathered, the preponderance of evidence standard has been met, therefore the allegation is substantiated. Substantiated The investigation into the allegation, staff did not protect resident from being exploited, revealed the following. It was reported that the facility allowed Resident 1 (R1) to be financially exploited and that the former Administrator assisted in financially exploiting R1. No other details were provided. The former Administrator denied the allegation. R1 was moved into the facility on February 28, 2024 by their responsible party and moved out April 2, 2024. R1 has been diagnosed with Dementia. R1 moved out of the facility and subsequently passed away and was not interviewed. A record review shows the Power of Attorney paperwork for R1 is incomplete and is therefore not valid. The former Administrator reported they never received completed Power of Attorney paperwork from the responsible party or any other family member. It was reported that the former Administrator allowed a family member to visit R1 against the wishes of the responsible party and this led to the financial exploitation of R1. R1's family member would not respond to the LPA's request for an interview and subsequently passed away. The former Administrator reported that they informed R1's responsible party that they could not deny visitation without a court order or restraining order. R1's responsible party did not respond to the LPA's request for an interview. 3 out of 3 staff members interviewed had no knowledge of R1 being financially exploited. None of the evidence gathered supports the allegation, therefore the allegation is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. Violations are being cited per California Code of Regulations, Title 22 division 6. An exit interview was conducted and a copy of the report and appeals rights was provided.the state’s words, verbatim · CDSS document, Dec 30, 2025 · control 22-AS-20240710083946

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(16) · Plan of correction due date: Jan 9, 2026

(16) To receive or reject medical care or other services. This requirement was not met as evidenced by on March 8, 2024, R1 missed receiving 4 routine medications on the morning medication pass at 9:00am. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 30, 2025

Plan of correction: Licensee agrees to train medication staff on CCR 87468.1 and on facility medication administration procedures. Facility to forward proof of training to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Ruth Martinez and Garlli Tat made an unannounced visit to conduct the required annual inspection. LPAs met with Ashley Davidson, Resident Care Director and explained the reason for the visit. LPAs and the Resident Care Director toured the facility. Facility is licensed for 55 ambulatory, 68 non-ambulatory, and 12 bedridden residents. Facility has an approved hospice waiver for 25 residents. Delayed egress approved for 1st floor. This facility consists of two main areas. The assisted living and the memory care which is on the 1st floor. Memory care unit protected by delayed egress exits. Facility is a three story building with 78 Assisted Living resident rooms and 38 Memory Care resident rooms. The facility also houses 2 courtyards, a living room on each floor, a bistro, 2 dining rooms, 2 community patios, Staff break room, a Med rooms on each floor and a parking structure. LPAs and Resident Care Director began the tour of the physical plant of the facility. LPAs observed the memory care has a secured perimeter and delayed egress. The delayed egress exits were tested and found to be operational. The memory care is on the first floor and has a dining area, activity room and outdoor patio with shaded seating. LPAs toured the resident rooms in memory care. The resident rooms toured had all the required furnishings. There is an activity room with puzzles and games along arts and crafts supplies. There is a Large screen TV mounted on the wall in the activity room. No obstacles or hazards observed in the memory care. LPAs and the Resident Care Director toured the assisted living which is on the second and third floors. LPAs observed each stairway has an emergency evacuation chair. LPA observed the kitchen is clean and organized. LPA observed a bistro adjacent to the main dining room where residents can obtain Continued on LIC809-C different snacks and beverages selections than in the main dining area. The bistro offers snacks all day so residents may dine when convenient. LPA observed menus for both areas and the food offered is varied and healthful. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Maintenance records were observed in the main kitchen. The emergency food and water supply is stored in a storage room. LPA observed the refrigerators and freezer are at the required temperatures. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and shower was free of mold/mildew. Several resident bathrooms were tested for water temperature in floors 1-3 and water temperature measured between 115.7 and 118.5 degrees F in tested bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPAs pushed the restroom call button in various resident rooms and response times were under five minutes. LPAs observed several residents who appeared clean, and happy. There are activity rooms with games and reading materials on the second and third floor. Each activity room has a large screen TV. The assisted living section has a courtyard on the first floor with shaded seating. No bodies of water observed. There is also shaded balconies on the second and third floor for assisted living residents. No obstacles or hazards observed in the assisted living section. Fire extinguishers are fully charged and mounted throughout the facility. Smoke detectors and sprinkler system are tested by an outside agency, and LPAs was provided with testing documentation, last testing was done July 25, 2025. LPA inspected that medication is centrally stored in a safe locked location; facility has a medication room on each floor. LPA observed and inspected medication carts that are used to dispense meds to residents and observed medication was labeled and stored inaccessible to residents in care, no discrepancies observed. LPAs reviewed 6 resident files, no discrepancies observed. LPA reviewed 5 staff files. All staff had the required training. No discrepancies observed. Staff members present are background cleared and associated to the facility. Based on the observations made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with the facility representative and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Aug 25, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Managing Director Lee Kaufmann and explained the reason for the visit. LPA and the Managing Director toured the facility. Facility is a three story building with 78 Assisted Living resident rooms and 38 Memory Care resident rooms. The facility also houses 2 courtyards, a living room on each floor, a bistro, 2 dining rooms, 2 community patios, Staff break room, a Med room on each floor and a parking structure. LPA observed the memory care has a secured perimeter and delayed egress. The delayed egress exits are operational. The memory care is on the first floor and has a dining area, activity room and outdoor patio with shaded seating. LPA toured the resident rooms in memory care. The resident rooms toured had all the required furnishings. The smoke detectors tested operational. There is an activity room with puzzles and games along arts and crafts supplies. There is a Large screen TV mounted on the wall in the activity room. No obstacles or hazards observed in the memory care. LPA the Managing Director toured the assisted living which is on the second and third floors. LPA observed each stairway has an emergency evacuation chair. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The emergency food and water supply is stored in a storage room. LPA observed the refrigerators and freezer are at the required temperatures. The resident rooms inspected in assisted living have the required furnishings. Hot water measured 112.0 degrees Fahrenheit in resident bathrooms. All bathrooms inspected are clean and operational. There are activity rooms with games and reading materials on the second and third floor. Each activity room has a large screen TV. The assisted living section has a courtyard on the first floor with shaded seating. No bodies of water observed. There is also shaded balconies on the second and third floor for assisted living residents. No obstacles or hazards observed in the assisted living section. The last emergency drill took place on July 9, 2024. LPA observed the medication are kept locked in the medication room on the second floor and in the medication room on the first floor in memory care. LPA reviewed 4 resident medications, no discrepancies observed. LPA reviewed 5 resident files, no discrepancies observed. LPA reviewed 5 staff files. All staff had the required training. No discrepancies observed. Staff members present are background cleared and associated to the facility. No deficiencies observed during the inspection. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Aug 12, 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.