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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005902
Report Date: 11/29/2021
Date Signed: 11/29/2021 03:48:50 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 OBISPO TERRACE SENIOR LIVINGFACILITY NUMBER:
306005902
ADMINISTRATOR:PRIESMAN, SABRINAFACILITY TYPE:
740
ADDRESS:32200 DEL OBISPO STREETTELEPHONE:
(949) 496-8802
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:120CENSUS: 54DATE:
11/29/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Sabrina PriesmanTIME COMPLETED:
04:05 PM
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Licensing Program Analysts (LPAs) Joseph Alejandre and Jerome Haley made an unannounced visit to conduct a case management visit to follow up on a death report submitted to the Agency on 11/29/21. LPAs were greeted and granted entry to the facility. LPAs met with Executive Director Sabrina Priesman and explained the reason for the visit. LPAs interviewed the Executive Director and staff concerning resident 1 (R1). LPAs requested documents for R1, physician's report, needs & service plan and emergency contact information. LPAs reviewed the report with the Executive Directork. No deficiencies are being cited as a result of today's 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: 11/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2021
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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