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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004721
Report Date: 08/31/2021
Date Signed: 08/31/2021 01:24:50 PM

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:SAN JUAN CAPISTRANO SENIOR LIVINGFACILITY NUMBER:
306004721
ADMINISTRATOR:JOSEPH FRANZFACILITY TYPE:
741
ADDRESS:31741 RANCHO VIEJO RDTELEPHONE:
(949) 248-8855
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:125CENSUS: 63DATE:
08/31/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Ninad DadabhoyTIME COMPLETED:
01:44 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by facility staff. LPA met with Health and Wellness Director Ninad Dadabhoy. Bryan Hadley's Administrator's Certificate expires 2/23/2023. LPA consulted Health and Wellness Director concerning Guardian and background clearances and the current requirements concerning Covid-19 mitigation. Facility mitigation plan is pending review. Last emergency drill (fire) was conducted on 8/29/2021. Fire monitoring system is maintained by Johnson Control, the system was last tested on 8/30/2021. LPA observed the dining room is clean and organized. LPA observed residents having lunch in the dining room. LPA observed all staff were wearing masks. LPA reviewed the inspection tool, infection control, with the Health and Wellness director. LPA observed hand sanitizing stations throughout the facility. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of this report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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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