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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003665
Report Date: 03/28/2022
Date Signed: 03/28/2022 12:09:53 PM


Document Has Been Signed on 03/28/2022 12:09 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:DEL SOL TRES ELDERLY CARE HOMEFACILITY NUMBER:
306003665
ADMINISTRATOR:JIMENEZ, ELIZABETHFACILITY TYPE:
740
ADDRESS:26452 VIA DEL SOLTELEPHONE:
(949) 357-6255
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 6DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Administrator Jon MayorgaTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection to this facility. LPA met with Administrator (AD) Jon Mayorga; and stated the purpose of this visit.

This facility is a single level structure and licensed for 6 non-ambulatory; and with hospice waiver for three. On this visit, there were two resident under hospice care.

LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, there were six residents in care and two staff members on the floor. LPA toured the interior and exterior portions of the facility. There were two shared and two private resident's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Hardwired Smoke, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were provided with handrails and nonskid floor mats. Hot water was measured at 105 degrees Fahrenheit. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Facility met the minimum 2 day perishable and 7 day no perishable food stock requirements. LPA observed personal protective equipment in place. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair. Grounds were free of tripping hazards. LPA Marin reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to 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. Facility will ensure safety of residents in care while repairs and remodelling are done within the facility.

For this visit, no citation was issued.

LPA Marin conducted an exit interview with AD Mayorga and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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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