| Freedom Village Healthcare Center | |
| 23442 El Toro Road, Lake Forest, California 92630 | |
| (949) 472-0277 | |
| Name | Freedom Village Healthcare Center |
|---|---|
| Location | 23442 El Toro Road, Lake Forest, California |
| Certified By | Medicare and Medicaid |
| No. of Certified Beds | 52 |
| Occupancy Rate | 77.12% |
| Medicare ID (CCN) | 555391 |
| Legal Business Name | Casa Pacifica |
| Ownership Type | For Profit - Partnership |
| NPI Number | 1841354354 |
| Match | Confirmed listed in Medicare enrollment records |
| Organization Name | Casa Pacifica |
| Doing Business As | Freedom Village |
| Address | 23442 El Toro Rd, Lake Forest, CA 92630 |
| Phone Number | 949-472-4700 |
| NPI Number | 1437338217 |
| Match | Possible same name, address or phone number |
| Organization Name | Innovative Lake Forest Operations, LLC |
| Address | 23442 El Toro Rd, Lake Forest, CA 92630 |
| Phone Number | 800-584-8084 |
| Ratings from Surveys (Inspections): | |
| Ratings from Quality Measures: | |
| Ratings from Staffing Data: | |
| Overall Rating: |
|---|
| Staffing Measure | Provider | National Avg. |
|---|---|---|
| Total nurse staff hours per resident per day | 5.03 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.7 | 0.69 |
| Licensed practical nurse (LPN) hours per resident per day | 1.47 | 0.86 |
| Nurse aide hours per resident per day | 2.86 | 2.32 |
| Total nurse staff hours per resident per day on the weekend | 4.28 | 3.42 |
| RN hours per resident per day on the weekend | 0.66 | 0.48 |
| Physical therapist hours per resident per day | 0.14 | 0.07 |
| Total nursing staff turnover | 35.8% | 45.8% |
| Registered nurse turnover | 14.3% | 42.9% |
| Number of administrators who have left the nursing home | 0 | 0.5 |
| Cited for abuse, neglect or exploitation of residents (Care Compare abuse icon) | No |
| Number of Fines | 0 |
| Total Amount of Fines in Dollars | $0 |
| Number of Payment Denials | 0 |
| Total Number of Penalties | 0 |
| Date | Deficiency | Harm Level | Status |
|---|---|---|---|
| Jun 2, 2026 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842, Resident Assessment and Care Planning, Complaint inspection | Minimal harm potential, pattern | Corrected by Jun 17, 2026 |
| Nov 26, 2025 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Dec 18, 2025 |
| Nov 26, 2025 | Allow residents to self-administer drugs if determined clinically appropriate. F0554, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Dec 18, 2025 |
| Nov 26, 2025 | Reasonably accommodate the needs and preferences of each resident. F0558, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Dec 18, 2025 |
| Nov 26, 2025 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. F0609, Freedom from Abuse, Neglect, and Exploitation, Standard inspection | Potential for harm, isolated | Corrected by Dec 18, 2025 |
| Nov 26, 2025 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Dec 18, 2025 |
| Nov 26, 2025 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Dec 18, 2025 |
| Nov 26, 2025 | Provide safe and appropriate respiratory care for a resident when needed. F0695, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Dec 18, 2025 |
| Nov 26, 2025 | Ensure medication error rates are not 5 percent or greater. F0759, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Dec 18, 2025 |
| Nov 26, 2025 | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. F0761, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Dec 18, 2025 |
| Nov 26, 2025 | Provide and implement an infection prevention and control program. F0880, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Dec 18, 2025 |
| Nov 26, 2025 | Implement a program that monitors antibiotic use. F0881, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Dec 18, 2025 |
| Nov 26, 2025 | Develop and implement policies and procedures for flu and pneumonia vaccinations. F0883, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Dec 18, 2025 |
| Nov 26, 2025 | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. F0887, Infection Control, Standard inspection | Potential for harm, isolated | Corrected by Dec 18, 2025 |
| Nov 26, 2025 | The resident has the right to receive notices in a format and a language he or she understands. F0574, Resident Rights, Standard inspection | Minimal harm potential, pattern | Corrected by Dec 18, 2025 |
| Nov 26, 2025 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. F0628, Resident Rights, Standard inspection | Minimal harm potential, pattern | Corrected by Dec 18, 2025 |
| Nov 26, 2025 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842, Resident Assessment and Care Planning, Standard inspection | Minimal harm potential, pattern | Corrected by Dec 18, 2025 |
| Sep 26, 2025 | Provide enough food/fluids to maintain a resident's health. F0692, Quality of Life and Care, Complaint inspection | Potential for harm, isolated | Corrected by Oct 26, 2025 |
| Dec 26, 2024 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. F0842, Resident Assessment and Care Planning, Complaint inspection | Minimal harm potential, pattern | Corrected by Jan 13, 2025 |
| Dec 6, 2024 | Respond appropriately to all alleged violations. F0610, Freedom from Abuse, Neglect, and Exploitation, Complaint inspection | Potential for harm, isolated | Corrected by Dec 29, 2024 |
| Dec 6, 2024 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684, Quality of Life and Care, Complaint inspection | Potential for harm, isolated | Corrected by Dec 29, 2024 |
| Oct 24, 2024 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812, Nutrition and Dietary, Standard inspection | Potential for harm, pattern | Corrected by Nov 17, 2024 |
| Oct 24, 2024 | Allow residents to self-administer drugs if determined clinically appropriate. F0554, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Nov 17, 2024 |
| Oct 24, 2024 | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. F0578, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Nov 17, 2024 |
| Oct 24, 2024 | Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. F0582, Resident Rights, Standard inspection | Potential for harm, isolated | Corrected by Nov 17, 2024 |
| Oct 24, 2024 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689, Quality of Life and Care, Complaint inspection | Potential for harm, isolated | Corrected by Nov 17, 2024 |
| Oct 24, 2024 | Provide enough food/fluids to maintain a resident's health. F0692, Quality of Life and Care, Standard inspection | Potential for harm, isolated | Corrected by Nov 17, 2024 |
| Oct 24, 2024 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Nov 17, 2024 |
| Oct 24, 2024 | Ensure each resident’s drug regimen must be free from unnecessary drugs. F0757, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Nov 17, 2024 |
| Oct 24, 2024 | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. F0758, Pharmacy Service, Standard inspection | Potential for harm, isolated | Corrected by Nov 17, 2024 |
| Quality Measure | Provider | National Avg. |
|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.93 | 13.87 |
| Percentage of long-stay residents who lose too much weight | 1.75 | 5.19 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7 | 0.82 |
| Percentage of long-stay residents with a urinary tract infection | 1.37 | 1.59 |
| Percentage of long-stay residents who have depressive symptoms | 0 | 12.8 |
| Percentage of long-stay residents who were physically restrained | 0 | 0.13 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0 | 3.23 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100 | 93.55 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.68 | 82.04 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.43 | 1.56 |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.82 | 14.07 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.02 | 19.52 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100 | 95.46 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.24 | 79.75 |
| Percentage of long-stay residents with pressure ulcers | 4.3 | 4.62 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.06 | 19.01 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.64 | 15.38 |
Trabuco Hills Post Acute Location: 25652 Old Trabuco Road, Lake Forest, California 92630 Phone: (949) 380-9380 |