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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005198
Report Date:
11/15/2021
Date Signed:
11/15/2021 12:07:59 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:
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:
5
DATE:
11/15/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:15 AM
MET WITH:
Herminia Zuehl
TIME COMPLETED:
12:21 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 staff. LPA explained the reason for the visit. The facility has 6 bedrooms and 3 bathrooms. Oxygen in use sign is posted on the front door. One of the residents periodically uses Oxygen. All of the bedrooms are private. LPA toured the kitchen. LPA observed a two day perishable and 7 day non-perishable food supply on hand. LPA observed knives locked in a kitchen cabinet. Medications are kept locked in a closet. The kitchen is cleaned and organized. The fire extinguishers are fully charged. LPA observed the fireplace in the living room is screened. Administrator Herminia Zuehl arrived at 10:40am. LPA and Administrator toured the facility. Smoke/Carbon monoxide detectors tested operational. LPA observed all of the bedrooms had the required furnishings and each room had enough space to accommodate the residents and their belongings. LPA observed all 3 bathrooms were clean and operational. LPA and Administrator toured the garage. The garage is used for storage and kept off limits to residents. LPA and Administrator toured the backyard. No bodies of water observed. LPA observed a sitting area with an umbrella and chairs. The backyard gate is operational. No obstacles or hazards observed. The facility has a mitigation plan that has been approved. LPA consulted with the Administrator concerning the Guardian background check system. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME:
Luz Adams
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
(951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE:
11/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/15/2021
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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