LAKE FOREST COUNTRY HOME III

22741 COSTA BELLA, Lake Forest CA 92630

Facility 306001261 · RESIDENTIAL CARE ELDERLY (740)

6 bedsLatest official report Jan 30, 2026Licensed

Additional info
Licensee
RIVAS, CARMEN T.
Administrator
RIVAS, CARMEN T.
Contact
RIVAS, CARMEN T.
License first date
Jan 23, 2001
License effective date
Jan 23, 2001
District office
ORANGE COUNTY RO · (714) 703-2840
Regional office
22
Clients served
985 - RCFE / HOSPICE

Summary

The available records show 1 Type A and 3 Type B deficiencies for this facility.

Most recent inspection
Jan 30, 2026
Most recent deficiency
Jan 30, 2026

No later report is available, so the records do not show what happened afterward.

What Type A and Type B mean
Type A
Violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
Type B
Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.

Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.

At a glance

Counts cover the five-year public record. Typical figures are the median for the 984 Orange County facilities licensed for 6 or fewer beds.

In the available public five-year record, CCLD published 4 reports for this facility: 4 inspections, 0 complaint investigations, and 0 licensing or administrative records.

Those records contain 1 Type A and 3 Type B deficiencies.

0 deficiencies have explicit official correction or clearance evidence in the loaded records.

Official inspections
4

About the same as most this size

1 in the last 12 months

Recorded deficiencies
4

More than the typical 1

1 in the last 12 months

Type A deficiencies
1

Most this size have none

0 in the last 12 months

Type B deficiencies
3

More than the typical 1

1 in the last 12 months

Substantiated complaints
0

Most this size also have none

0 in the last 12 months

Repeated topics
0

Last 36 months

Repeated topics

Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.

No topic repeats in the last 36 months

No deficiency topic appears in more than one report during that window. This does not establish that nothing repeated earlier in the five-year record, and it is not a statement about current conditions.

Official report history

All preserved reports from the most recent to the oldest, sortable by report type.

Inspection
Fire safety and emergency preparednessType B
Official classification
Type B
Official code
1569.69(a)(2)
Regulation authority
HSC

What the official deficiency says

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in two out of two staff on duty did not have the required training completed and documented, which poses safety risk to persons in care.

Official plan of correction

POC Due Date: 02/13/2026 Plan of Correction Licensee agrees to conduct and complete training for staff on duty, and send proof of correction to LPA Via email by P.O.C due date.

Plan of correction recorded
Correction not verified in available records
View official report
Inspection
Admission, assessment, and evictionType B
Official classification
Type B
Official code
87458(a)
Regulation authority
CCR

What the official deficiency says

(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health and safety risk to persons in care. During file review, LPA observed Resident #2 (R2) did not have a medical assessment on file.

Official plan of correction

POC Due Date: 01/24/2025 Plan of Correction Licensee agreed to submit a completed Medical Assessment for Resident #2 to LPA via email or fax by POC date.

Plan of correction recorded
Correction not verified in available records
View official report
Admission, assessment, and evictionType B
Official classification
Type B
Official code
87507(a)
Regulation authority
CCR

What the official deficiency says

(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care. Per file review, LPA observed that Resident #1 (R1) does not have an Admission Agreement on file.

Official plan of correction

POC Due Date: 01/24/2025 Plan of Correction Licensee agreed to submit a completed Admission Agreement for Resident #1 to LPA via email or fax by POC date.

Plan of correction recorded
Correction not verified in available records
View official report
Inspection
Background checksType A
Official classification
Type A
Official code
87355(a)(e)(1)
Regulation authority
CCR

What the official deficiency says

This requirement is not met as evidenced by: LPAs observation and the infromation provided to LPA Haley by staff at the facility. Upon calling the Regional Office for verification LPA Haley was informed there is no Criminal Record Clearance for Nathaniel. Deficient Practice Statement Based on observation and interview with staff, the licensee did not comply with the section cited below: 87355 Criminal Record Clearance (a) the department shall conduct a criminal record review of all individuals specified in Health and safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence or prescense in the facility, based on the results of such review. (e) All individuals subject to a criminal record review pursuant to Health and Safety Code section 1569.17(b) shall prior to working, residing, or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department

Official plan of correction

POC Due Date: 02/17/2022 Plan of Correction Licensee will ensure all employees have a criminal record clearance before being allowed to work, or volunteer at the facility.

Plan of correction recorded
Correction not verified in available records
View official report

Source and limits

California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.

Read the data methodology