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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005700
Report Date: 04/26/2022
Date Signed: 04/26/2022 01:51:15 PM


Document Has Been Signed on 04/26/2022 01:51 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:DEL SOL I RSLFACILITY NUMBER:
306005700
ADMINISTRATOR:MAYORGA, JONATHANFACILITY TYPE:
740
ADDRESS:26462 VIA DEL SOLTELEPHONE:
(949) 357-6255
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 0DATE:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator (AD) Jonathan MayorgaTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection to this facility. LPA met with Administrator (AD) Jon Mayorga; and stated the purpose of this visit.

This facility is a two level structure and licensed for 6 non-ambulatory of which 1 may be bedridden and with hospice waiver for two. LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, there were no residents in care. Facility is undergoing renovation. LPA toured the interior and exterior portions of the facility. There were two shared and two private resident's rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Hardwired Smoke, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were provided with handrails and nonskid floor mats. Hot water was measured at 105 degrees Fahrenheit. LPA observed a locked drawer for sharp kitchen items; locked cabinet for medications; and locked storage space for cleaning supplies. Facility met the minimum 2 day perishable and 7 day non- perishable food stock requirements. LPA observed personal protective equipment in place. Fire extinguisher was mounted and charged. For the exterior portion, facility had outside furniture in good repair. Grounds were free of tripping hazards. Pool feature was enclosed by permanent fence system and access doors were observed to be locked. LPA Marin reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that an support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. AD agreed to notify Community Care Licensing Division (CCLD) Orange Office once the facility is ready to accept its new resident.
For this visit, no deficiency was observed for areas covered. No citation was issued.

LPA Marin conducted an exit interview with AD Mayorga and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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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