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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005902
Report Date:
03/17/2022
Date Signed:
03/17/2022 04:12:05 PM
Document Has Been Signed on
03/17/2022 04:12 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 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:
45
DATE:
03/17/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:40 PM
MET WITH:
Peggy DeSilva
TIME COMPLETED:
04:26 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Joseph Alejandre and Edward Tapia made an unannounced visit to conduct the required annual inspection. LPAs were greeted and granted entry by Business Office Manager Peggy DeSilva. LPAs explained the reason for the visit. LPAs and the Business Office Manager toured the facility. LPAs observed the PUB 475 poster is 8 1/2 by 11 inches. LPAs observed the facility kitchen is clean and organized. LPAs observed a 2 day perishable and a 7 day non-perishable food supply on hand. LPAs observed the emergency food and water supply kept secured in a storage room. LPAs observed resident rooms had the required furnishings. LPAs observed medication is stored in the medication room and inaccessible to residents. LPAs observed there is an activity room and a game room and large room used for visiting. All rooms had seating areas for residents. No obstacles or hazards observed in the facility. LPAs toured the two outdoor seating areas. Both areas had shaded areas with tables and chairs for the residents to sit outside. LPAs observed a fountain in the North West outdoor patio. The fountain is raised and the water level is less than a foot. The fountain does not pose a hazard to residents. LPAs did not observe any obstacles or hazards outside the facility. The last fire safety inspection was conducted by the Orange County Fire Authority on 12/20/2021. LPAs reviewed staff and resident files. During the visit LPAs observed the residents participating in bingo. 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 Adams
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
(951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE:
03/17/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/17/2022
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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