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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000372
Report Date: 05/13/2025
Date Signed: 05/13/2025 04:06:28 PM

Document Has Been Signed on 05/13/2025 04:06 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/
DIRECTOR:		GOODWIN, JEREMIAHFACILITY TYPE:
740
ADDRESS:23792 MARGUERITE PKWYTELEPHONE:
(949) 458-1176
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92692
CAPACITY: 120CENSUS: 79DATE:
05/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Jeremiah GoodwinTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Atria Del Sol. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the facility and explained the reason for the visit. Facility is licensed for 64 ambulatory and 51 non-ambulatory of which 5 may be bedridden. Facility has an approved hospice waiver for 11 residents and the facility currently has 5 residents on hospice care. Jeremiah Goodwin has an administrator certificate expiring on 07/28/2025.

LPA Lyman along with Administrator Goodwin toured the facility at 11:05 AM. LPA toured the physical plant, checked food service, facility records and the first aid kit. Facility appears to be clean, safe, and sanitary. Facility consists of three stories housing 63 apartments in assisted living, 27 apartments in memory care, multiple outside areas, two dining rooms, beauty salon, fitness area, movie theater, bistro and two activity areas. Resident apartments had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident restrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 108.5 and 113.1 degrees F in facility restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Staff responded within 5 minutes for emergency pull. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors as well as a first aid manual. LPA observed cleaning supplies are secured. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Facility is keeping a log of freezer/ refrigerator temperatures and all were in range. Smoke detectors and fire inspections are conducted annually by an outside company, Systems Specialist, with the last inspection date in December 2024. CONTINUED ON LIC 809C DATED 05/13/2025

NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Kimberly Lyman
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/13/2025
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Facility has carbon monoxide detectors in facility hallways and were tested to be operational. Fire extinguishers are fully charged. LPA observed evacuation chairs at stairwells. LPA toured the outside grounds and there is ample shaded seating for residents. LPA observed ample emergency food and water. LPA reviewed the emergency disaster plan and infection control plan during the visit. Plans are thorough and complete. Facility conducts quarterly emergency drills with the last drill conducted on 03/30/2025. Facility provides activities in the form of games, exercise, and outings. LPA observed residents participating in activities during the visit. LPA spoke with residents during the visit who stated satisfaction with facility services and verbalized feeling safe. LPA observed no health or safety concerns during the visit.
LPA reviewed select resident and staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Staff files reviewed contained required documentation such as health screen/TB, and criminal record clearance.

Due to time constraints, LPA to return at a later date to review medication administration and storage.



Based on the observations made during today's visit, no deficiencies are being cited.
Exit interview conducted and a copy of this report was given at time of visit.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Kimberly Lyman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC809 (FAS) - (06/04)
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