306005697-8-26-2020-22-AS-AMAN-BSUST5-20200826140857

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005697
Report Date: 08/26/2020
Date Signed: 08/26/2020 02:09:08 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:	DEL SOL IV RSL		FACILITY NUMBER:	306005697
ADMINISTRATOR:	MAYORGA, JONATHAN		FACILITY TYPE:	740
ADDRESS:	27041 MALLORCA LANE		TELEPHONE:	(949) 357-6255
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 0	DATE:	08/26/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator Jonathan Mayorga		TIME COMPLETED:	02:15 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	As precautionary measures during the Coronavirus 2019 pandemic, Licensing Program Analysts (LPAs) Albert Marin and Ashraf Hanna conducted an announced prelicensing visit to this facility via video teleconference with Licensee and Administrator (AD) Jonathan "Jon" Mayorga. LPA stated the purpose of this visit. On May 4, 2020, Orange County Fire Authority granted the fire clearance of 5 non-ambulatory and 1 bedridden for this facility. Based on the video teleconference with AD Mayorga, LPA observed that there were no residents in care. The facility is a two-level structure. The lower level had 2 private and 2 shared resident's rooms; and the upper level was for staff members use only. Resident rooms were provided with linens, adequate furniture, and adequate storage space. Hallway was provided with adequate light and kept free of tripping hazards. 1 private and 1 common bathroom were observed to have grab bars and non-skid floor mats. Hot water was measured at 117 degrees Fahrenheit. Smoke and carbon monoxide, and auditory exit alarms were tested to be operational. Fire extinguisher was mounted and charged. Kitchen appeared clutter free. Sharp kitchen utensils, cleaning supplies, medications and facility files will be kept inaccessible to unauthorized use and access. Facility met the 2 day perishable and 7 day non-perishable food stock requirements. LPA observed the posting requirements in place. Exterior features had adequate open space with two exit self-latching and self-closing gates. Per visual teleconference, the facility was observed to be in substantial compliance with the Title 22 Division 6 of the California Code of Regulations. LPA Marin and conducted a modified Component III Orientation with AD Mayorga who is currently working as administrator for existing licensed facilities. AD Mayorga is NOT planning to advertise for Dementia Special Care Program. (Page 1/2)

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: DEL SOL IV RSL	FACILITY NUMBER: 306005697
	VISIT DATE: 08/26/2020

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AD Mayorga agreed to notify the Community Care Licensing Division (CCLD) Orange Office before admitting their first resident in the facility.

The prelicensing visit and Component III is now complete. LPA Marin will forward this report to the Centralized Applications Bureau for review.

LPAs Marin and Hanna conducted a phone exit interview with AD Mayorga. LPA read the report. LPA will send copy of this report via email; and in turn AD agreed to acknowledge the receipt of this report.

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SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Albert Marin	TELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2020

LIC809 (FAS) - (06/04)

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