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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005198
Report Date: 11/07/2024
Date Signed: 11/07/2024 03:11:43 PM

Document Has Been Signed on 11/07/2024 03:11 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ADAGIO SAN JUANFACILITY NUMBER:
306005198
ADMINISTRATOR/
DIRECTOR:
HERMINIA ZUEHLFACILITY TYPE:
740
ADDRESS:31822 SAN JUAN CREEK CIRCLETELEPHONE:
(949) 388-9219
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
11/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Amy ZuehlTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection LPA met with Administrator Amy Zuehl and explained the reason for the visit. The facility is licensed for a capacity of 6 non-ambulatory residents of which, 6 can be bedridden and a hospice waiver for 6. The facility is a one story home with a living room, dining room, kitchen, 6 bedrooms, 3 bathrooms, laundry room and a 2 car garage. LPA observed the See Something, Say Something poster (PUB 475) posted next to the front door. LPA and the Administrator toured the facility. LPA observed all resident rooms had the required furnishings and bed linens. LPA observed all 3 bathrooms are clean and operational. Hot water measured 114.8 degrees Fahrenheit in all bathrooms. LPA observed the fireplace in the living room is screened. LPA observed the kitchen is clean and organized. LPA observed the 5 burner gas stove lights unassisted. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. Knives are kept locked in a kitchen cabinet and cleaning supplies are kept locked under the kitchen sink. LPA observed medications are kept locked in the hall closet. Smoke detectors/carbon monoxide detectors tested operational. LPA observed extra linens and blankets are stored in the hall closet. The last emergency drill was conducted on October 4, 2024. LPA observed the fire extinguisher in the dining room is fully charged. LPA inspected the first aid kit, the first aid kit has all the required elements. LPA and the Administrator toured the garage. The garage is used for storage and kept locked. LPA observed tools, furniture supplies, emergency food and water being stored in the garage. LPA and the Administrator toured the backyard. The backyard has a fountain next to the back wall. LPA observed a table with an umbrella and chairs to sit outside. The path on the side of the house leading to the exit gate clear and free of obstacles. The exit gate is latched, self-closing and operational. No obstacles or hazards observed in the backyard. LPA reviewed 2 staff files. Both staff members have the required training and CPR. Both staff members are background cleared and associated to the facility. LPA reviewed 5 resident files and medications. No discrepancies observed. LPA observed and the Administrator verified there is no internet device for dedicated resident use. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
Sheila SantosTELEPHONE: (714) 334-2062
Joseph AlejandreTELEPHONE: 714-705-6018
DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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