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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003006
Report Date: 11/16/2022
Date Signed: 11/16/2022 10:00:05 AM


Document Has Been Signed on 11/16/2022 10:00 AM - 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:CALIFORNIA LIFESTYLESFACILITY NUMBER:
306003006
ADMINISTRATOR:ROY/SHEILA MOELLERFACILITY TYPE:
740
ADDRESS:840 CAMINO DE LOS MARESTELEPHONE:
(949) 498-0035
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:6CENSUS: 6DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Roy Moeller and Miguel JuarezTIME COMPLETED:
10:20 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Miguel Juarez and explained the reason for the visit. Administrator Roy Moeller arrived during the visit. Administrator Roy Moeller has an administrator certificate expiring on 10/21/2023.

At 8:49 AM, LPA toured the facility with Administrator Moeller. Facility has six residents in care during today's visit with one on hospice care. LPA observed residents relaxing in the facility. LPA spoke with residents and all residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Hand washing signs are posted in the restrooms. LPA observed the screening station in the entrance of the facility. Facility screens all visitors to the facility. Facility has covid precaution postings as well as all required department postings. LPA toured the kitchen and observed ample food supply as well as operational appliances. Smoke detectors/ carbon monoxide detectors tested operational during today's visit. Facility has completed the mitigation plan and plan has been approved. LPA observed emergency food and water as well as the first aid kit which contained all required items. LPA toured the outside grounds and observed the outside visitation area. Exit gates are unlocked and self latching. Residents participate in activities such as exercise. LPA observed the locked medication storage area. Toxins/ sharps are secured during today's visit. Facility has ample supple of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPA reviewed select resident files which contained all required documentation including emergency information and updated physician reports.
LPA consulted with Administrator regarding the importance of taking staff and resident temperatures daily and documenting as well as documenting visitor temperatures.
No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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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