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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005198
Report Date:
10/20/2020
Date Signed:
10/21/2020 08:17:33 AM
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:
ADAGIO SAN JUAN
FACILITY NUMBER:
306005198
ADMINISTRATOR:
HERMINIA ZUEHL
FACILITY TYPE:
740
ADDRESS:
31822 SAN JUAN CREEK CIRCLE
TELEPHONE:
(949) 388-9219
CITY:
SAN JUAN CAPISTRANO
STATE:
CA
ZIP CODE:
92675
CAPACITY:
6
CENSUS:
6
DATE:
10/20/2020
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
03:28 PM
MET WITH:
Amy Zuehl
TIME COMPLETED:
04:05 PM
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Licensing Program Analyst (LPA) Joseph Alejandre conducted a Health and Safety visit via FaceTime due to Covid-19 pre-cautionary measures. LPA was greeted by Administrator Herminia "Amy" Zuehl. LPA explained the reason for the visit. LPA and the Administrator toured the facility. LPA observed the facility had working water and electricity and gas. Administrator reported the heater/air conditioner is operational. LPA observed the smoke detectors are operational. LPA observed all 6 residents in their rooms. The facility was neat and clean and no hazards were observed. All the bathrooms were clean and operational. LPA observed a 7 day supply of non-perishable and 2 day supply of perishable food in the kitchen. LPA observed extra supplies and food in the garage. LPA observed 3 caregivers all wearing masks. LPA did not observe any Health and Safety concerns. An exit interview was conducted and a copy of the this report is being provided via email. Email return receipt confirms the Administrator received the report.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
(951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE:
10/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/20/2020
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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