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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005902
Report Date: 07/07/2022
Date Signed: 07/07/2022 01:28:12 PM


Document Has Been Signed on 07/07/2022 01:28 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 LIVINGFACILITY NUMBER:
306005902
ADMINISTRATOR:SABRINA PRIESMANFACILITY TYPE:
740
ADDRESS:32200 DEL OBISPO STREETTELEPHONE:
(949) 482-3594
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:120CENSUS: DATE:
07/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Sabrina PriesmanTIME COMPLETED:
01:41 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to follow up on an incident report received July 5, 2022. LPA was greeted and granted entry to the facility. LPA met with the Executive Director Sabrina Priesman and explained the reason for the visit. The incident report received stated, Resident 1 (R1) left the facility on 7/4/2022 around 8:30pm. Staff could not locate R1 and searched the facility to but could not locate R1. Staff contacted the Orange County Sheriff. R1 was located by the Sheriff and returned to the facility at 9:00pm. R1 was found a block away from the facility. Staff assessed R1 and escorted them to their room. No injuries were noted. A review of records for R1 indicate R1 cannot leave the facility unassisted. Even though R1 left the facility unassisted, once it was discovered they had left, the staff acted according to their policy/procedure and searched the facility and contacted law enforcement and the responsible party. R1 was assessed by the facility nurse (LVN) and did not require any first aid or emergency treatment. R1 now has a one on one care companion. LPA consulted with the Executive Director concerning elopement, Based on the observations, record review and interviews, the following violation is being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided to the Executive Director.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
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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Document Has Been Signed on 07/07/2022 01:28 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/08/2022
Section Cited

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Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
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Based on interviews and a review of incident reports and records. Licensee failed to ensure care and supervision was provided to R1. R1 eloped out of the facility and was found by the Sheriff and returned to the facility. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
LIC809 (FAS) - (06/04)
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