LAKEVIEW HOMES MISSION VIEJO

Official classification

Type B

Official code

87468(c)(2)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation conducted during the tour of the physical, the licensee did not comply with the section cited above as the posted notice is not the mandated size, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/30/2024 Plan of Correction Licensee will replace the poster with a version in the adequate size and inform LPA of the replacement before the plan of correction due date.

Official classification

Type B

Official code

1569.695(a)(2)

Regulation authority

HSC

What the official deficiency says

(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above as the one-page version of the Emergency and Disaster Plan LIC610E is still observed to be in use which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/15/2024 Plan of Correction Facility staff stated they would update the current Emergency and Disaster Plan onto the current form LIC610E and provide a copy of the plan to LPA before the plan of corrections due date.

Official classification

Type A

Official code

87465(g)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care … (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health… This requirement was not met as evidenced by: Based on interviews and documents, on 4/18/2023 the facility did not call 9-1-1 immediately after R1’s fall and injury and only took R1 to urgent care the next day, which posed an immediate health risk to persons in care. CIVIL PENALITY ASSESSED.

Official plan of correction

Licensee stated they will conduct training for staff on responding to resident injuries and calling 9-1-1 and will submit proof to LPA by POC due date.

Deadline recorded: Oct 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(8)

Regulation authority

CCR

What the official deficiency says

87468.2 … Personal Rights … (a) … (8) To be free from … intimidation, and verbal, mental … abuse. This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure residents are not shouted at by staff, which poses an immediate personal rights risk to persons in care.

Official plan of correction

Licensee stated they will conduct training for staff on proper interactions with residents and submit proof to LPA by POC due date.

Deadline recorded: Oct 31, 2023. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

1569.625(b)(2)

Regulation authority

HSC

What the official deficiency says

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by: Deficient Practice Statement Based on documents, the licensee did not ensure 2 out of 2 staff completed the 40-hour initial or 20-hour annual training, which poses a potential safety risk to persons in care.

Official plan of correction

POC Due Date: 11/27/2023 Plan of Correction Licensee stated they will have staff complete the training and submit proof to LPA by POC due date.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

Type B: CCR 87303(a) – 87303 Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. … for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and documents, the licensee did not ensure the facility contained a fire extinguisher inspected within the last year, which poses a potential health and safety risk to persons in care.

Official plan of correction

POC Due Date: 11/27/2023 Plan of Correction Licensee stated they will have the fire extinguisher inspected or replaced immediately and submit proof to LPA by POC due date.

Official classification

Type B

Official code

80061(b)

Regulation authority

CCR

What the official deficiency says

The California Code of Regulations Section 80061 on Reporting Requirements states that " Upon the occurrence (...) of any of the events specified (....) below, a report shall be made to the licensing agency. Events reported shall include the following: Any injury to any client which requires medical treatment. Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. " This requirement is not met as evidenced by unreported incidents on 04/01/22 and 11/24/22. This failure to report poses a potential risk to the health and safety of the persons in charge.

Official plan of correction

Licensee and administrator will review the cited regulations and ensure that an adequate reporting process is in place for any future incidents.

Deadline recorded: Jan 14, 2023. A deadline is not proof that correction was completed.