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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005946
Report Date:
06/30/2022
Date Signed:
06/30/2022 03:24:19 PM
Document Has Been Signed on
06/30/2022 03:24 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:
SERRA SOL
FACILITY NUMBER:
306005946
ADMINISTRATOR:
LOPEZ, JANELLE
FACILITY TYPE:
740
ADDRESS:
31451 AVENIDA LOS CERRITOS
TELEPHONE:
(916) 836-8022
CITY:
SAN JUAN CAPISTRANO
STATE:
CA
ZIP CODE:
92675
CAPACITY:
70
CENSUS:
31
DATE:
06/30/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:33 PM
MET WITH:
Susie Peterson,Khatera Bahadory
TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Executive Director (ED) Susie Peterson and Director of Nursing Khatera Bahadory. LPA explained the reason for the visit. LPA and the Director of Nursing toured the facility. Staff reported that the last emergency drill was conducted on Monday 6/27/22. LPA observed the See Something Say Something Poster (PUB 475) in the main lobby. Facility is an RCFE with a capacity of 70. LPA measured the hot water in rooms 110 and 107. Hot water measured 112.6 in room 110 and 111.6 in room 107. LPA observed all fire extinguishers were fully charged. Facility has two levels. The main level where the entrance of the facility is and the lower level which is currently vacant and off limits to residents. LPA toured the kitchen and dining room. LPA observed a 2 day perishable and 7 day non-perishable food supply on hand. LPA observed the kitchen and dining room were clean and organized. LPA observed an activity room with puzzles. LPA observed a room with a TV and a screened fireplace. There is an outdoor sitting area for residents. No obstacles or hazards observed outside or inside of the facility. Facility has submitted the infection control plan. 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:
06/30/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/30/2022
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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