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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005949
Report Date: 03/23/2022
Date Signed: 03/23/2022 02:09:31 PM


Document Has Been Signed on 03/23/2022 02:09 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: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: 86DATE:
03/23/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:26 PM
MET WITH:Ninad DadabhoyTIME COMPLETED:
02:21 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a post licensing visit (mitigation). LPA met with Health & Wellness Director, Ninad Dadabhoy. LPA and the Health & Wellness Director toured the facility. LPA observed resident rooms had the required furnishings. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed the dining area is clean and has enough space to accommodate the residents. LPA observed the emergency food and water supply. All fire extinguishers are fully charged. LPA observed the fireplace in the main lobby is screened. The facility has 4 outdoor patios with shaded seating areas for residents. One area is for memory care and has a delayed egress exit. LPA observed on the north side outdoor patio there is an empty fountain. LPA and Health & Wellness Director toured the memory care area. LPA tested the delayed egress exits in the memory care patio and the memory care area. Delayed egress system is operational and the alarms are working. LPA observed all medications are kept locked in the medication room. LPA observed hand sanitizing stations throughout the facility. Facility has a 30 day supply of PPE. Last fire drill was conducted on 3/14/22. Facility provided documentation that the fire sprinkler system has been tested on 2/24/22 and is operational with no defects. No obstacles or hazards observed inside or outside of the facility. Facility has a mitigation plan that has been approved. LPA did not observe any deficiencies 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 AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2022
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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