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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004637
Report Date: 01/30/2024
Date Signed: 01/30/2024 03:54:38 PM


Document Has Been Signed on 01/30/2024 03:54 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: 2DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Lisa Gaitan- AdministratorTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived unannounced for the purpose to conduct the Required 1-Year Annual Inspection. LPA was greeted and granted entry after stating the purpose of the visit to Caregiver Perla Sanches. Administrator (Admin) Lisa Gaitan arrived on site to assist with the inspection around 11:00am.

LPA conducted a tour of the physical plant accompanied by Caregiver Valeria Ochoa. The following was observed during the tour: This is a single story facility comprised of five resident bedrooms and two resident bathrooms, laundry room, living room, office, and a two-car garage. LPA toured the outside grounds. There was shading and sufficient seating for residents. The exit gate was self-closing and self-latching.

LPA observed two residents and two caregivers on duty. The two resident bedrooms are spacious and easily accommodates the residents' furnishings. Furniture for each resident bedrooms were inspected. The bathrooms were clean, faucets, and toilets were operational. The hot water temperature initially measured at 124.3 in the shared bathroom and 123.2 degrees Fahrenheit in the private bathroom. The water heater was readjusted and corrected during the visit which then measured at 118.4 and 117.6 degrees Fahrenheit. There was sufficient supply of clean linens. LPA observed a two-day supply of perishables and a seven-day supply of non-perishable food as required by regulation. Carbon monoxide, smoke detectors, and the auditory devices were tested and operational. The fire extinguisher was serviced on 06/16/2023. Medications, toxins, and sharps were locked and inaccessible to the residents. Facility had ample supply of emergency supplies including food/water. LPA reviewed two out of the two resident and staff files.

LPA reminded the following: Licensee to pay the licensing fees by 03/02/2024, to ensure at least one staff with a CPR/First Aid training on duty on premise at all times, and to accurately document the current list of medications on the Medication Administration Record.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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: SOLEIL SENIOR LIVING
FACILITY NUMBER: 306004637
VISIT DATE: 01/30/2024
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Based on the observations made during today's visit, no deficiency is being cited as per the Title 22 Division 6 Chapter 2 of the California Code of Regulations. Two Advisory Notes (LIC9102s) were issued during the visit.

An exit interview was conducted with Administrator Lisa Gaitan, and a copy of this report including the LIC809C, and the LIC92102s were provided at the end of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC809 (FAS) - (06/04)
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