306005902-2-26-2021-22-AS-JALE-BYLR65-20210226114411

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005902
Report Date: 02/25/2021
Date Signed: 02/26/2021 11:44:49 AM

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 OBISPO TERRACE SENIOR LIVING		FACILITY NUMBER:	306005902
ADMINISTRATOR:	PRIESMAN, SABRINA		FACILITY TYPE:	740
ADDRESS:	32200 DEL OBISPO STREET		TELEPHONE:	(949) 496-8802
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY:	120	CENSUS: 49	DATE:	02/25/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Sabrina Priesman		TIME COMPLETED:	03:15 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	Licensing Program Analyst (LPA) Joseph Alejandre contacted Administrator Sabrina Priesman via iPhone to conduct the prelicensing inspection via FaceTime due to Covid-19 precautionary measures. The facility is currently operating under license number 306003830. The Licensee Corporation is changing. Facility will retain the same name Del Obispo Terrace Senior Living with a new Licensee and new License number 306005902. The new facility will be licensed as an RCFE with a capacity of 120. The Fire Clearance has been approved by Orange County Fire Authority, fire inspector Marco Heredia, on 12/30/2020. The application was received by CCL on 9/23/2020. Facility phone number is 949-496-8802. LPA Alejandre toured the facility via FaceTime with Administrator Sabrina Priesman. Structure; Facility is two stories with 91 resident rooms, and a center courtyard area for residents. Bedrooms Residents. All resident rooms have their own bathroom. LPA observed that rooms had a night stands, lamps and chairs and enough closed space to accommodate resident's belongings. Bathrooms. were clean, faucets and toilets were operational, grab bars secure and showers had slip mats. Water temperature measured 112 degrees Fahrenheit. Linens & Hygiene Supplies. Linen closet was well stocked with linens and towels. Emergency Phone Numbers, Exit Plan & Menu: Reviewed. Food Service. seven days nonperishable food supply and two day perishable food supply reviewed. LPA inspected the Kitchen and Dining room. Both were clean and free of hazards. Carbon Monoxide, Smoke Detectors, Fire Extinguishers were observed. All monitors tested during fire clearance inspection and are operational. Toxins: cleaning supplies were kept locked in a storage closet and is inaccessible to residents. Medication room is kept locked and only accessible to staff. First-Aid Kit & Activity Supplies. observed and available. Resident & Staff Files No files reviewed. LPA observed an outdoor patio area with seating for residents. LPA observed a water fountain that was empty in the courtyard. LPA observed all staff were wearing masks and residents were social distanced. LPA observed Covid-19 signs and precautions throughout the facility. LPA observed the front desk area had a check in area with a station to screen visitors for temperature and symptoms. LPA observed that the facility had a 30 day supply of PPE. LPA conducted component III presentation with the Administrator.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2021

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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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 OBISPO TERRACE SENIOR LIVING	FACILITY NUMBER: 306005902
	VISIT DATE: 02/25/2021

NARRATIVE

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During the visit LPA Alejandre explained the process of this application and also about the post licensing visit once the facility is licensed. Administrator was informed that the facility meets Title 22 Division 6 of the California Code of Regulations. Facility is now ready for licensure.

Applicant was informed today that the final approval will be processed by the CAB specialist in Sacramento.

An exit interview was conducted and a copy of this report, LIC809 was explained and provided to Administrator Sabrina Priesman via email, electronic read receipt confirms Administrator receiving the report.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2021

LIC809 (FAS) - (06/04)

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