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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004532
Report Date: 04/12/2024
Date Signed: 04/12/2024 01:46:59 PM


Document Has Been Signed on 04/12/2024 01:46 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:ASSISTED SENIOR HOMEFACILITY NUMBER:
306004532
ADMINISTRATOR:Z. GLOUNERFACILITY TYPE:
740
ADDRESS:24741 PRISCILLATELEPHONE:
(949) 248-9415
CITY:DANA POINTSTATE: CAZIP CODE:
92629
CAPACITY:6CENSUS: 6DATE:
04/12/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Lucy FloresTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 03/11/2024. LPA was greeted and granted entry into the facility and explained the reason for the visit. Licensee arrived during the visit.

*Deficiency cited under Title 22 Regulation 87303(a) pertaining to Maintenance and Operation has been cleared. Licensee repaired/ replaced smoke detectors. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87465(h)(2) pertaining to Care of Persons with Dementia has been cleared. During today's visit, medications are secured. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 1569.695(c) pertaining to Emergency Drills has been cleared. Licensee provided proof of last emergency drill. Licensee has complied with the terms of the POC.

*Deficiency cited under Title 22 Regulation 87412(c) pertaining to Personnel Records has been cleared. LPA observed proof of training in the staff files. Licensee has complied with terms of the POC.

Licensee addressed items on the advisory note issued 03/11/2024.
Licensee has been advised to remain in compliance with all items in the facility.

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: 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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