<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000372
Report Date: 05/12/2022
Date Signed: 05/12/2022 12:33:17 PM


Document Has Been Signed on 05/12/2022 12:33 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ATRIA DEL SOLFACILITY NUMBER:
306000372
ADMINISTRATOR:GOODWIN, JEREMIAHFACILITY TYPE:
740
ADDRESS:23792 MARGUERITE PKWYTELEPHONE:
(949) 458-1176
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY:120CENSUS: 84DATE:
05/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH: Jeremiah GoodwinTIME COMPLETED:
12:52 PM
NARRATIVE
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
Licensing Program Analysts (LPAs) Celine De Perio and Albert Marin conducted an unannounced visit for the purpose of conducting a required annual visit. LPAs were greeted and granted entry into the facility by Executive Director (ED) Jeremiah Goodwin and explained the reason for the visit. ED also has an Administrator’s certificate that expiring on 07/27/2023. Facility has a COVID screening procedure that is completed per visitor with temperature check, and self-assessment questionnaire.

At 9:30 AM, LPAs toured the facility with Administrator. Facility has eighty four residents in care during today's visit with 2 residents on hospice care, 31 in memory care and 53 in assisted living. Facility consists of Assisted Living and Memory Care “Life Guidance” units. LPAs observed residents relaxing, socializing, and participating in activities in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. Observed resident rooms had clean bed linens and rooms and bathrooms were free from odor. All rooms are observed to be single rooms, and in the memory care unit, two rooms with individual doors to separate the resident, with a shared bathroom. LPAs tested emergency pull cord in random rooms (Room #131 and #219) and was observed to be operational, and hot water temperatures were measured between 105-114 degrees Fahrenheit. Carbon monoxide detectors were observed in common hallways and are operational. LPAs toured the exterior ground of facility and observed multiple outside visitation areas with provided shaded areas. LPAs observed the medication room and medication cart used for residents with computer. LPAs observed that facility has posted the enlarged 20" x 26" "Let Us Know" poster. ED/AD presented the emergency disaster plan in facility. LPAs De Perio and Marin informed and reviewed the Coronavirus 2019 (COVID 19) mitigation plan of the facility with ED/AD Goodwin. LPAs discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

Continued on Page 2.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ATRIA DEL SOL
FACILITY NUMBER: 306000372
VISIT DATE: 05/12/2022
NARRATIVE
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
LPAs observed first-aid kit with all required items in facility and in company vehicles along with all fire extinguishers charged. Facility annual fire alarm inspection was conducted on 12/15/2021 and 12/16/2021. Facility has emergency evacuation chairs at the top of both stairwells, and delayed egress door was tested and observed to be operational. LPAs observed an ample supply of emergency food and water. Facility provided documentation of fire inspection for each room, along with smoke detectors functions.

No citation was issued during today's visit. LPAs De Perio and LPA Marin conducted. An exit interview was conducted with ED/AD Jeremiah Goodwin and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2