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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005949
Report Date: 06/01/2021
Date Signed: 06/01/2021 02:23:04 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:CAPISTRANO SENIOR LIVINGFACILITY NUMBER:
306005949
ADMINISTRATOR:GARCIA, CYNTHIAFACILITY TYPE:
741
ADDRESS:31741 RANCHO VIEJO ROADTELEPHONE:
(844) 375-0029
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:125CENSUS: 64DATE:
06/01/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Cynthia GarciaTIME COMPLETED:
02:37 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made this announced visit to conduct the pre-licensing inspection. LPA was greeted and granted entry by Administrator Cynthia Garcia. Cynthia Garcia's Administrator's certificate expires 4-1-2022. Application received on 12/16/2020. Facility is to operate a continuing care retirement community, capacity is for 125 non-ambulatory residents. LPA and Administrator toured the facility. Facility is a two story building and surrounding parking lot. No bodies of water observed. LPA inspected resident rooms, kitchen, dining rooms, laundry room, medication room and theater room. LPA observed no obstacles or hazards in the facility. Call system is operational. LPA observed a wired smoke/carbon monoxide detector in each room. System tested during Fire inspection and on 5/27/21 by Johnson Control inc. Hot water temperature measured 105 degrees Fahrenheit. LPA toured the courtyard and outside parking lot, no obstacles or hazards observed. All fire extinguishers were fully charged. LPA observed the emergency chair lift mounted next to each stairway door. Facility telephone number is 949-248-8855. LPA observed that the kitchen was clean and knives are kept secured. First-Aid Kit & Activity Supplies. observed and available. Resident & Staff Files facility, no files reviewed. Delayed Egress exit doors are operational. Fire clearance was approved by Orange County Fire Authority Inspector Marco Heredia 05/27/2021. Facility meets Title 22 Division 6 of the California Code of Regulations. Facility is ready for licensure. LPA explained the process of this application and also about post licensing visit once the facility is licensed. Applicant was informed today that the final approval will be processed by the CAU supervisor in Sacramento. Component III was completed with applicant. An exit interview was conducted and a copy of this report, LIC809 was explained and provided to Cynthia Garcia.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
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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