Activcare Laguna Hills.

This unannounced case management visit is being conducted by Licensing Program Analysts (LPAs) Ruth Martinez and Nancy Guillen to follow up on incident reported to Community Care Licensing. LPAs met with Patricia Miller, Executive Director and explained the nature of the visit. Incident report dated 5/1/26 for a witnessed fall involving resident R1. R1 was in a common area of the facility when it was observed R1 fell cause of fall is unknown. Staff assisted R1 immediately and R1 was observed to be confused and did not recall how the fall occurred. R1 complained of pain in left side extremities. 911 was called immediately and sent out for further evaluation. R1 underwent surgery due to injury and was sent out to a skilled nursing. Upon today’s visit LPAs observed R1 arriving at the facility clean, groomed and in good spirit. R1 was re-assessed prior to return to facility and was determined they needed a higher level of care, moved to another wing of the facility and required 1:1 care. R1 upon admissions was determined to be a fall risk resident and fall prevention measure were implemented. LPAs toured the facility and R1’s bedroom and did not observe any concerns with the bedroom. LPAs obtained copies of pertinent documents. LPA found that facility acted appropriately and in a timely manner to address the incident and all other immediate attention to incident in question. LPA did not observe any immediate and/or safety risks in or out of the facility. Based on the observation made during today's visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Executive Director and a copy of this LIC809 report was provided and left at the facility.

This unannounced case management visit is being conducted by Licensing Program Analysts (LPAs) Ruth Martinez and Nancy Guillen to follow up on incident reported to Community Care Licensing. LPAs met with Patricia Miller, Executive Director and explained the nature of the visit. Incident report dated 1/13/26 for an unwitnessed fall involving resident R1. R1 was on the phone with their spouse when they had a fall. Spouse immediately called the front desk, and staff was sent to check on R1. R1 was found on the ground in their side by the foot of the bed. R1 was unable to recall the event only when they fell out of bed. R1 complained of no movement to right leg. Staff immediately called 911 and were transferred to hospital for evaluation. At hospital R1 was noted with an injury, had surgery and was sent to a skilled nursing facility. Upon return to facility R1 was re-assessed and moved to a different wing of the facility that requires more care and supervision. R1 has in house physical therapy and now has had a change of level in care. R1 was observed at the time of visit to be clean, well dressed and in good spirit. LPAs obtained copies of pertinent documents. LPA found that facility acted appropriately and in a timely manner to address the incident and all other immediate attention to incident in question. LPA did not observe any immediate and/or safety risks in or out of the facility. Based on the observation made during today's visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations. This report was reviewed with Executive Director and a copy of this LIC809 report was provided and left at the facility.

During the health and safety walk-through, LPA did not observe any concerns related to the allegation. LPA observed residents eating lunch, and the menu reflected that lunch included a turkey sandwich or grilled chicken sandwich and mixed fruit. Regarding the allegation, “Staff gave resident the wrong medication,” LPA interviewed five staff members, all of whom denied the allegation. LPA also conducted a telephone interview with Resident 1’s responsible party (R1’s RP), who advised that R1 had never been given the wrong medication. LPA was unable to obtain reliable resident interviews because the residents were unable to provide consistent statements due to their current medical and cognitive condition. In addition, LPA observed the medication administration process and noted that the Medication Technician verified the resident’s name against the prescription label and the resident’s photograph on the screen before administering medication. Regarding the allegation, “Staff are restraining resident,” LPA did not observe any physical signs on any resident, such as bruising or other visible marks that would indicate possible restraint or abuse. LPA also interviewed five staff members, all of whom denied the allegation. In addition, LPA conducted a telephone interview with R1’s responsible party, who stated that R1 had never been restrained. Based on interviews, observations, and record review, the Department was unable to determine that the allegations occurred as reported. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove or disprove that the alleged violations occurred. Therefore, the allegations are deemed unsubstantiated. An exit interview was conducted Executive Director (ED) Patricia Miller and a copy of this report was provided.

In addition, LPA reviewed Resident 1’s records, including progress notes, admission records and the physician’s report, and did not identify any information supporting the allegation. Regarding the allegation, “Staff handled resident roughly causing a bruise,” LPA interviewed five staff members and attempted to interview five residents. All five staff members denied the allegation and stated that staff do not handle residents in a rough manner. The residents were unable to provide reliable statements due to their current medical and cognitive condition. LPA also conducted a phone interview with Resident 1’s responsible party, who denied the allegation and stated that facility staff were helpful during R1’s stay. R1’s RP further reported that Resident 1 had fallen from the bed and that facility staff immediately arranged for Resident 1 to be sent to the hospital for evaluation. Facility records also showed that a Special Incident Report was submitted regarding an unwitnessed fall that occurred on February 24, 2025. The records further showed that Resident 1 was transported to the hospital, later discharged without serious injury, and placed on a 72-hour observation period by the facility. Based on interviews, observations, and record review, the Department was unable to determine that the allegations occurred as reported. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove or disprove that the alleged violations occurred. Therefore, the allegations are deemed unsubstantiated. An exit interview was conducted Executive Director (ED) Patricia Miller and a copy of this report was provided.

During resident interviews, LPA did not observe any incontinence odor or unusual smell. Residents appeared clean, well-groomed, and hygienically maintained. In addition, record review showed that the facility conducts checks on residents every two hours and maintains a log of those checks. LPA also reviewed the Community Care Licensing (CCL) electronic log for any reported falls or Special Incident Reports (SIRs) involving Resident 1 (R1) and found no reported incidents or falls for R1. It was also alleged that “Staff do not answer residents' call buttons in a timely manner” and “Staff do not ensure residents have adequate nighttime supervision”. All six staff members interviewed denied both allegations. In addition, according to the facility’s “Detailed Event Report” for the call button system, call requests were responded to in a timely manner and no calls were left unattended. LPA also tested the call button system during the visit and observed staff response within 0.54 seconds. Regarding nighttime staffing, facility records showed that at the time of the alleged incident, there were four caregivers and one nurse on duty during the overnight shift. Based on observations, interviews, and record review, the Department is unable to determine that the allegations occurred as reported. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove or disprove that the alleged violations occurred. Therefore, the allegations are deemed Unsubstantiated. An exit interview was conducted with the Executive Director, and a copy of this LIC 9099 report was left at the facility.

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by receptionist. LPA met with Patricia Miller, Executive Director and LPA explained the nature of the visit. Facility is licensed for 72 non-ambulatory residents, of which 17 may be bedridden. Facility has an approved hospice waiver for 15 residents. There are 12 residents currently on hospice during today's visit. This facility consists of a memory care unit which are protected by delayed egress exits. LPA Martinez along with Executive Director toured the inside and outside of the physical plant of the memory care unit. LPA observed three dining halls for residents. LPA observed menus mounted on the wall and the food offered is varied and healthful with an everyday optional menu. 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. During the tour LPA observed residents having lunch in all the three dining areas. LPA inspected that medication is centrally stored in a safe locked location; facility has a medication room. 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. Facility has 4 bedroom wings and 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. Various resident bathrooms were tested for water temperature and water temperature measured between 109 and 115.3 degrees F in tested bathrooms. Facility has common showers and bedrooms have a full bathroom or half bathroom in each room. Resident Continued on LIC809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 bath towels, toiletries and personal hygiene supplies were adequately stocked. LPA observed several residents who appeared clean, and happy. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked in a locked storage closet of each wing of the bedrooms. LPA observed a posted activity schedule for memory care residents. LPA observed residents in the memory care unit with care staff present. LPA observed and verified the delayed egress exits in all the patios of the facility. Fire extinguishers are fully charged and had a service date of February 14, 2025, and were observed to be mounted throughout the facility. LPA verified that smoke detectors were serviced, and last service date was February 16, 2025, and are tested annually. Sprinkler systems are tested every 5 years and last service date was August of 2021. Both are serviced and tested by an outside vendor of First Choice Fire Protection. LPA reviewed testing documentation and observed facility to have services logs. Emergency drills are being conducted monthly with the last drill conducted on November 30, 2025. Outside grounds have ample shaded seating for residents. LPA reviewed five resident files and four staff files. All resident files contained required documentation including updated physician reports and care plans. Staff files contained required documentation including health screens, first aid, and fingerprint clearance. 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 Executive Director and a copy of this report was provided to the facility.

Records review revealed that on July 26, 2022, facility census was 21 and out of the 21 there are 13 residents that wear diapers. End of shift reports does not reflect any resident’s unable to change diapers, however it does reflect residents to be combative, confused, not wanting to participate in activities, and not wanting to get dressed. Charting notes stated what was done to resolve the situation, notes do not reflect any resident to be unable to change their diaper. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with Executive Director and a copy of this LIC9099 report was left at facility.

and then can become combative/agitated with staff. Staff (S3) states they provide care for R1 and has prepared the supplies for brushing teeth and provided cueing. This month R1’s care for dental was changed to full assistance with oral care. Review of resident (R1) records the services plan from October 2024, and March 2025, revealed that dental needs/details: set up, verbal cueing with minimum assist. Services plan from April 2025 full assistance needed with oral care, resident previously able to complete oral care with verbal cueing. Currently unable to perform oral hygiene independently and at times refuses caregiver assistance, demonstrating resistance, and assistance with morning and bedtime dental care. LPA reviewed logs in place for new changes in R1 services needs. Based on the information mentioned above, the Department is unable to ascertain if the allegation occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed Unsubstantiated. An exit interview was conducted with Executive Director and a copy of this LIC9099 report was left at facility.

Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility and was greeted and granted entry by receptionist. LPA met with Patricia Miller, Executive Director and LPA explained the nature of the visit. Facility is licensed for 72 non-ambulatory residents, of which 17 may be bedridden. Facility has an approved hospice waiver for 15 residents. There are 12 residents currently on hospice during today's visit. This facility consists of a memory care unit which are protected by delayed egress exits. LPA Martinez along with Executive Director toured the inside and outside of the physical plant of the memory care unit. LPA observed three dining halls for residents. LPA observed menus mounted on the wall and the food offered is varied and healthful with an everyday optional menu. 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. During the tour LPA observed residents having lunch in all the three dining areas. LPA inspected that medication is centrally stored in a safe locked location; facility has a medication room. 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. Facility has 4 bedroom wings and 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. Resident bathrooms were tested for water temperature and water temperature measured between 105.5 and 107.7 degrees F in tested bathrooms. Facility has common showers and bedrooms have a full bathroom or half bathroom in each room. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPA observed several residents who appeared clean, and happy. LPA observed that toxic chemicals, cleaning solutions and Continued on LIC809-C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 disinfectants are stored locked in a locked storage closet of each wing of the bedrooms. LPA observed a posted activity schedule for memory care residents. LPA observed residents in the memory care unit with care staff present. LPA observed and verified the delayed egress exits in all the patios of the facility. Fire extinguishers are fully charged and had a service date of February 19, 2024, and were observed to be mounted throughout the facility. LPA verified that smoke detectors were serviced, and last service date was January 22, 2024, and are tested annually. Sprinkler systems are tested every 5 years and last service date was August of 2021. Both are serviced and tested by an outside vendor of First Choice Fire Protection. LPA reviewed testing documentation and observed facility to have services logs. Emergency drills are being conducted monthly with the last drill conducted on November 18, 2024. Outside grounds have ample shaded seating for residents. LPA reviewed six resident files and six staff files. All resident files contained required documentation including updated physician reports and care plans. Staff files contained required documentation including health screens, first aid, and fingerprint clearance. 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 Executive Director and a copy of this report was provided to the facility.

Minimal rodent activity noted during this service.” Service report also stated, “Please allow 3 to 5 days to take full effect.” On August 14, 2024, Building Maintenance Work Order Request Form was submitted stating "ants in nurse room!" Per same Work Order, on the same date, the area was treated and signed off by Staff 1 (S1). On August 21, 2024, Building Maintenance Work Order Request Form was submitted reporting ants in two resident bedrooms. Per same Work Order, on the same date, the area was treated and signed off by S1. On August 23, 2024, Building Maintenance Work Order Request Form was submitted reporting ants in a resident bedroom. Per same Work Order, on the same date, area was treated and signed off by S1. On August 29, 2024, Building Maintenance Work Order Request Form was submitted reporting ants in another resident bedroom. Per same Work Order, on the same date, area was treated and signed off by S1. On September 03, 2024, Building Maintenance Work Order Request Form submitted reporting ants in a fourth resident’s bedroom. Per same Work Order, on the same date, the area was treated and signed off by S1. On September 3, 2024, at 11:19 a.m., S1 attempted to schedule soonest appointment with a Pest Control Company via text message and an appointment was scheduled for September 12, 2024. Per Service Report from Pest Control Company dated September 12, 2024, "For today’s service, I treated around both exterior courtyards around all walkways, windows, as well as around base of buildings. I then treated the rest of the exterior of the building as well as inspected and refilled all rodent monitoring stations as needed. Minimal rodent activity noted during this service. Extra heavy treatment on exterior per customer request due to concerns about increasing pest sightings.” Service report also stated, “Please allow 3 to 5 days to take full effect.” On September 23, 2024, at 2:15 p.m. S1 reached out to Pest Control Company Representative via text message asking when they would be able to return to provide additional services and received no response. On September 24, 2024, at 8:47 a.m., S1 again reached out to Pest Control Representative via text message stating: "Please respond every morning I'm getting reports of ants...” Text message received from Pest Control Representative stated “I can be there around 2pm. I will call you when I get there." (Cont. LIC9099-C) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Per Service Report dated September 24, 2024, "Completed re-treatment for ants… I made sure to treat the base of the buildings as well as underneath all windows. I also inspected for all ant activity. No trails of ants found along exterior.” On September 25, 2024, during initial complaint investigation, LPA conducted a tour of the facility and observed select resident rooms alleged to have ants. LPA did not observe the presence of any ants or other pests in resident bedrooms, common areas, or exterior of the facility. Interviews were conducted with three staff, and five residents regarding the allegation. Three of three staff interviewed stated ants had been present in the facility, in common areas and resident rooms over the summer, however, stated that upon identifying the presence of ants, staff are to submit a maintenance ticket and it is addressed within 24 hours by maintenance staff. During their interview, maintenance staff, S1, stated that a Pest Control Company is contracted at least monthly and sprays treatment in a perimeter around the facility. Per S1, it was discovered there was a tree branch touching the roof of the facility and ants were avoiding the perimeter by climbing up the tree, onto the branch touching the roof, and obtaining access inside the facility that way. Per S1, once this was discovered, the area was treated immediately. S1 stated that since the tree branch discovery, the tree was trimmed, and the branch is no longer touching the roof of the facility. Two of five residents interviewed denied the presence of pest including ants in the facility or their bedroom. Three of five residents interviewed were unable to confirm or deny the presence of ants. Based on observations and information received during interviews conducted, LPA is unable to determine if staff are not keeping facility free from pests. Although the above allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore at this time the above allegation is unsubstantiated. An exit interview was conducted and copy of this report was provided at the end of the inspection.