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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004272
Report Date: 04/12/2024
Date Signed: 04/12/2024 11:30:21 AM


Document Has Been Signed on 04/12/2024 11:30 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 LIFESTYLES IVFACILITY NUMBER:
306004272
ADMINISTRATOR:ROY OR SHEILA MOELLERFACILITY TYPE:
740
ADDRESS:715 CALLE AMABLETELEPHONE:
(949) 388-7390
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:6CENSUS: 6DATE:
04/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:25 AM
MET WITH:Roy MoellerTIME COMPLETED:
11:50 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to California Lifestyles IV. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and met with Administrator Roy Moeller. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 2 residents and the home currently has 6 residents. There are 2 residents on hospice during today's visit.

LPA Lyman along with Administrator Moeller toured the facility at 8:45 AM. LPA toured the physical plant, checked food service, and the first aid kit. Facility appears to be clean, safe, and sanitary. The home consists of six resident bedrooms, four resident bathrooms, one staff room, one shared hall bathroom, living room, dining room, and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPA observed three residents with a half bed rails. 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 104.7 and 109 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. 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. During today's visit, auditory door alarms are operational. The entry door into the garage is secured. LPA observed a locked storage area for cleaning supplies under the kitchen sink. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for residents. Exit gates are unlocked. LPA observed ample emergency food and water supply. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 01/18/2024. Facility provides activities in the form of games and exercise. CONT ON LIC 9099C DATED 04/12/2024.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
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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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 IV
FACILITY NUMBER: 306004272
VISIT DATE: 04/12/2024
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At 9:30 AM, LPA reviewed six resident files and two staff files. Resident files contained required documents including admission agreements, current physician reports and resident appraisals. Staff files reviewed contained required documentation of annual training, health screen/TB, and criminal record clearance. At 10:15 AM, LPA reviewed medication storage and administration. Medications are stored in a locked cabinet and are audited monthly by staff. Medications are being administered per physician order.

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

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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