Incident investigation·June 28, 2022

Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced visit to Lake Forest Country Home #2 to conduct a case management (CM) visit. The purpose of this CM visit was to gather facility files in regards to the incident reported by facility administrator (AD) Carmen Rivas. LPA De Perio arrived at facility at 10:14 AM and was granted entry by staff on duty. LPA observed a total of 4 residents in care. LPA toured the interior portions of the facility with staff and resident. AD arrived at 10:33 AM and provided LPA copies of the following documents: SOC 341 (completed and provided LPA hard copy) Admission Agreement Resident file Staff file Emergency contact for resident Staff training Resident roster Personnel report Employee rights Statement Acknowledging Requirement to Report Suspected Abuse of Dependent Adults and Elders Criminal Record Statement Appraisal/Needs and Services Plan Personal Possession Liability Release LIC 602 Copy of written check provided by resident LPA De Perio conducted interviews and file reviews during visit. Due to time constrains, this case management visit will be completed at a later time. There were no deficiencies issued during this Case Management visit. No citation was issued during this visit. An exit interview was conducted with Licensee/Administrator Carmen Rivas and a copy of this report was provided at the time of this visit.