306005949-6-18-2025-22-AS-JALE-DHRU95-20250618152234

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005949
Report Date: 06/18/2025
Date Signed: 06/18/2025 03:22:55 PM

Document Has Been Signed on 06/18/2025 03:22 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 LIVING		FACILITY NUMBER:	306005949
ADMINISTRATOR/ DIRECTOR:	BRYAN HADLEY		FACILITY TYPE:	741
ADDRESS:	31741 RANCHO VIEJO ROAD		TELEPHONE:	(844) 375-0029
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY: 125		CENSUS: 103	DATE:	06/18/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:06 AM
MET WITH:	Bryan Hadley		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	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, 2027. Facility is a two story building with 114 resident rooms which includes a memory care unit. Facility is approved for delayed egress exits in the memory care unit. Facility is licensed for 125 non-ambulatory residents with a hospice waiver for 25. LPA and the Executive Director (ED) toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in 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. The refrigerators and freezers were at the required temperatures. LPA observed temperature logs posted on the refrigerator. LPA observed a 3 day emergency food supply stored in a supply closet. LPA observed a 3 day emergency water supply stored outside next to the courtyard. There is a courtyard outside the dining room in assisted living. The courtyard has shaded seating to sit outside and a fountain. 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 111.0 degrees Fahrenheit to 116.9 degrees Fahrenheit. There is a library next to the dining room with games and puzzles and a TV room for residents. During the visit residents were participating in a music activity in the great room next to the library. LPA observed all the fire extinguishers throughout the facility were fully charged. The facility has 4 stairwells. LPA observed an emergency evacuation chair at the top of each stairwell. LPA observed the facility has a desktop computer with internet access for dedicated resident use in the activity room.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 06/18/2025

NARRATIVE

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The last emergency drill was conducted on April 25, 2025. 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/courtyard in memory care with shaded seating for residents to sit outside. There is a delayed egress exit in the memory care patio/courtyard. All of the delayed egress exits in memory care tested operational. LPA observed medications are kept secured in a medication cart that is locked in the medication room. The first aid kit in the medication room has all the required elements. LPA interviewed staff and residents. LPA reviewed 5 staff files. LPA observed all 5 staff had more than 20 hours of annual training but did not have 4 hours of training for postural supports, restricted health conditions and hospice care. No other discrepancies observed. The staff, whose files were reviewed and the staff who were interviewed are all background cleared and associated to the facility. LPA reviewed 10 resident files, no discrepancies observed. LPA inspected resident medications, no discrepancies observed.

Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/18/2025 03:22 PM - It Cannot Be Edited

Created By: Joseph Alejandre On 06/18/2025 at 02:42 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAPISTRANO SENIOR LIVING	FACILITY NUMBER: 306005949
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of staff files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/03/2025
	Plan of Correction
1 2 3 4	Licensee agrees to have all caregivers trained in compliance with the above regulation, 4 hours of training specific to postural supports, restricted health conditions and hospice care. Licensee to submit proof of training to LPA by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:

	Joseph Alejandre
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2025

LIC809 (FAS) - (06/04)

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