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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005174
Report Date: 09/16/2021
Date Signed: 09/16/2021 03:01:48 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 CLEMENTE CARE HOMEFACILITY NUMBER:
306005174
ADMINISTRATOR:CASTEN, LUISITOFACILITY TYPE:
740
ADDRESS:2927 BONANZATELEPHONE:
(310) 975-5634
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY:6CENSUS: 6DATE:
09/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:18 AM
MET WITH:Luisito Casten and Joanne CastenTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Licensee/ Administrator Luisito Casten and explained the reason for the visit. Administrator Luisito Casten has an administrator certificate expiring on 02/04/2022. Administrator Joanne Casten arrived during the visit.

At 10:35 AM, LPA toured the facility with Administrator Luisito Casten. Facility has 6 residents in care during today's visit, with 2 on hospice care. Facility has bedridden fire clearance for one resident. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms are single occupancy and had the required elements as well as restrooms stocked with soap/ sanitizer. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet. Facility takes resident temperatures daily and documents. Facility has covid precaution postings as well as all required department postings. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. LPA observed an ample supply of emergency food and water. LPA toured the outside grounds and observed multiple shaded outside visitation areas. Exit gates are unlocked and self latching. LPA observed the locked medication storage area. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed six resident files during the visit and all files are up to date including emergency information. Most residents and all staff are vaccinated for Covid-19.

No deficiencies noted during today's visit. An exit interview was 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: 09/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021
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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