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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004637
Report Date: 08/14/2023
Date Signed: 08/14/2023 01:24:30 PM


Document Has Been Signed on 08/14/2023 01:24 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:SOLEIL SENIOR LIVINGFACILITY NUMBER:
306004637
ADMINISTRATOR:LISA GAITANFACILITY TYPE:
740
ADDRESS:23741 SINGAPORE STREETTELEPHONE:
(949) 716-7614
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 5DATE:
08/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Administrator - Scott Branson TIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced case management visit to the facility in conjunction with complaint: 22-AS-20230810160358. LPA met with facility administrator (AD) Scott Branson and explained reason for visit.

During the course of the complaint investigation, it was observed that the administrator certificate for AD Scott Branson expired on 8/4/2021.

For today's visit, a citation was issued.

An exit interview was conducted with AD Branson.

A copy of this report, and Appeal Rights were provided and explained.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023
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


Document Has Been Signed on 08/14/2023 01:24 PM - It Cannot Be Edited

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: SOLEIL SENIOR LIVING
FACILITY NUMBER: 306004637

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/18/2023
Section Cited
CCR
87407(e)

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87407 Administrator Recertification Requirements
(e) To apply for recertification... certificate holder shall submit to the Department’s Administrator Certification Section...
This requirement is not met as evidence by:
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As a plan of correction (POC) administrator will begin the renewal process of recertification and will provide proof to assigned LPA on or by 8/18/23.
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Based on LPA's observations, record reviews and interviews conducted, facility did not ensure that recertification was processed. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2