<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005198
Report Date: 09/23/2022
Date Signed: 09/23/2022 12:54:00 PM


Document Has Been Signed on 09/23/2022 12:54 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:ADAGIO SAN JUANFACILITY NUMBER:
306005198
ADMINISTRATOR:HERMINIA ZUEHLFACILITY TYPE:
740
ADDRESS:31822 SAN JUAN CREEK CIRCLETELEPHONE:
(949) 388-9219
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:6CENSUS: 6DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:53 AM
MET WITH:Herminia ZuehlTIME COMPLETED:
01:10 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
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 met with Administrator Herminia Zuehl. LPA explained the reason for the visit. LPA and Administrator toured the facility. 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. All of the bedrooms are private. LPA toured the kitchen. LPA observed a 2 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 clean and organized. The stove lights unassisted. The fire extinguisher in the kitchen is fully charged. LPA observed the fireplace in the living room is screened. 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. LPA consulted with the Administrator concerning continued Covid-19 mitigation requirements. No deficiencies observed during the visit. 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 AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1