Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
FREEDOM VILLAGE HEALTHCARE CENTER
LAKE FOREST, CA · 52 certified beds · Last Life Safety survey November 26, 2025
CMS Certification Number 555391 · first certified October 1989
Ownership
Independently operated (no chain recorded by CMS) · For profit - Partnership
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CA
19 citations — more than 49% of the 1,165 certified nursing homes in CA. Compared within CA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys on file averaged 8.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens December 2026 — about 1 month from now. This facility’s last Life Safety survey was November 2025. Facilities in CA are typically surveyed 12–16 months after the last one (median 14), measured over 1,814 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to about three years in Virginia. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
6 of the 19 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 19 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in CA, and nationally. Surveyors differ markedly between states, so the CA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 19 |
| Median facility in CA | 19 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 10, 2023 | 13 |
| October 24, 2024 | 4 |
| November 26, 2025 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2024-10-24 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2025-11-26 |
| K-0754 | Provide properly sized and located linen or trash receptacles. | 1 | 2023-02-10 |
| E-0015 | Address subsistence needs for staff and patients. | 1 | 2023-02-10 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2023-02-10 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2023-02-10 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2023-02-10 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2023-02-10 |
What the citations cover
- Smoke Deficiencies 6
- Emergency Preparedness Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Miscellaneous Deficiencies 3
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Emergency Preparedness Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 26, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (December 8, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 8, 2025) |
October 24, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (November 11, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 11, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (November 11, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 11, 2024) |
February 10, 2023 — 13 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (March 6, 2023) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (March 6, 2023) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (March 6, 2023) |
| E-0032 | Provide primary/alternate means for communication. | Deficient, Provider has date of correction (March 6, 2023) |
| E-0035 | Provide family notifications of emergency plan. | Deficient, Provider has date of correction (March 6, 2023) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (March 6, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 6, 2023) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (March 6, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 6, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 6, 2023) |
| K-0754 | Provide properly sized and located linen or trash receptacles. | Deficient, Provider has date of correction (March 6, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 6, 2023) |
| K-0926 | Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Deficient, Provider has date of correction (March 6, 2023) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.