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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005949
Report Date: 06/22/2024
Date Signed: 06/22/2024 01:13:47 PM


Document Has Been Signed on 06/22/2024 01:13 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CAPISTRANO SENIOR LIVINGFACILITY NUMBER:
306005949
ADMINISTRATOR:BRYAN HADLEYFACILITY TYPE:
741
ADDRESS:31741 RANCHO VIEJO ROADTELEPHONE:
(844) 375-0029
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:125CENSUS: 106DATE:
06/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Bryan HadleyTIME COMPLETED:
01:30 PM
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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 Bryan Hadley and explained the reason for the visit. Bryan Hadley's Administrator's certificate expires on February 3, 2025. Facility is approved for delayed egress exits in the memory care unit. Facility is a two story building with 114 resident rooms which includes a memory care unit. LPA and the Executive Director (ED) toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the hallway next to the main entrance. LPA and the ED toured the kitchen and dining room. LPA observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. LPA observed that the refrigerators and the freezers had temperature logs posted on them. The refrigerators and freezers were at the required temperatures. LPA and ED toured 10 resident rooms on the first and second floors. All resident rooms had the required furnishings and bed linens. All resident bathrooms were clean and operational. The hot water in the resident rooms inspected measured 106.7 degrees Fahrenheit to 111.5 degrees Fahrenheit. There is a library next to the dining room with games and puzzles and a TV room for residents. There are fire extinguishers on each floor and all fire extinguishers are fully charged. The facility has 4 stairwells. LPA observed an emergency evacuation chair at the top of each stairwell. The last emergency disaster drill was conducted on June 12, 2024. LPA and ED toured the memory care unit. LPA observed the resident rooms in memory care had the required furnishings and bed linens. There is an outdoor patio in memory care with shaded seating for residents to sit outside. The delayed egress exits in memory care tested operational. The fire alarm/fire detection system was inspected and tested operational on June 6, 2024. LPA observed medications are kept secured in a medication cart that is locked in the medication room. LPA interviewed staff and residents. LPA reviewed 5 staff files with no discrepancies observed. All staff files reviewed had the required annual training. LPA reviewed 10 resident files, no discrepancies observed. LPA inspected resident medications. LPA observed that Resident 1 was missing 2 of their 12 prescribed medications. No other discrepancies observed. No obstacles or hazards were noted inside or outside of the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 06/22/2024 01:13 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: CAPISTRANO SENIOR LIVING

FACILITY NUMBER: 306005949

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(b)
If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a review of Resident 1's medication and medication records, Resident 1 was missing 2 out of their 12 prescribed medications (Resident 1, was missing their MiraLax Packet 17 GM and Oxycodone HCI tablet 5 MG), the licensee did not comply with the section cited above in 1 out of 10 resident medications and records which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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Licensee agrees to contact R1's pharmacy and physician to order the medications for R1 or discontinue the medications if so ordered by the physician. Licensee agrees to forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 06/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/22/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CAPISTRANO SENIOR LIVING
FACILITY NUMBER: 306005949
VISIT DATE: 06/22/2024
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Deficiencies are being cited per title 22 Division 6 of the California Code of Regulations on the attached LIC 809D. An exit interview was conducted with the Executive Director and a copy of the report provided along with appeal rights
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2024
LIC809 (FAS) - (06/04)
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