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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003006
Report Date: 12/20/2024
Date Signed: 12/20/2024 03:13:54 PM

Document Has Been Signed on 12/20/2024 03:13 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:CALIFORNIA LIFESTYLESFACILITY NUMBER:
306003006
ADMINISTRATOR/
DIRECTOR:		ROY/SHEILA MOELLERFACILITY TYPE:
740
ADDRESS:840 CAMINO DE LOS MARESTELEPHONE:
(949) 498-0035
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
12/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:25 AM
MET WITH:Roy MoellerTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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
On this day Licensing Program Analysts (LPAs) Kimberly Lyman and Fred Arias made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 3 residents and the home currently has 4 residents, with 2 residents on hospice. Administrator (AD) Roy Moeller arrived shortly to conduct facility tour. AD Moeller has a valid certificate that expires on 10/17/2025. AD provided updated liability insurance that expires on 8/17/2025.

LPAs along with Administrator Moeller toured the facility at 7:46 AM. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 5 resident bedrooms, living room, dining room, and kitchen as well as 4 restrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105.6 degrees F and 113 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPAs toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPAs reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 10/17/2024. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of exercise. There is shaded outdoor seating for residents. Exit gates are unlocked and operational. LPAs observed the emergency food and water supply. LPAs reviewed four resident files and two staff files. CONTINUED ON LIC 809C DATED 12/20/2024.
Alisa OrtizTELEPHONE: (714) 703-2855
Kimberly LymanTELEPHONE: (714) 795-1497
DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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: CALIFORNIA LIFESTYLES
FACILITY NUMBER: 306003006
VISIT DATE: 12/20/2024
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
 All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. Medications are stored in a locked closet. Medications are being administered per physician order. Medications are audited daily by Administrator and monthly by facility physician.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2