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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005949
Report Date: 05/19/2022
Date Signed: 05/19/2022 11:02:03 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/11/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220511104605
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: 87DATE:
05/19/2022
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Brian HadleyTIME COMPLETED:
11:17 AM
ALLEGATION(S):
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Staff did not assist resident with their shower
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Brian Hadley joined the visit in progress.

During the course of the visit, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as shower schedule and shift report. Regarding the allegation that staff did not assist resident with their shower, the investigation revealed the following: Resident 1 (R1) had a preferred caregiver for showering. Caregiver switched shifts beginning May 2022 and is unable to provide shower due to R1's preferred shower time. R1 requests a 7 PM shower time and caregiver switched from evening shift to morning shift. Per interviews with staff, facility has attempted to work with resident in regards to shower time and caregiver providing the shower. R1 is refusing showers and facility provided documentation of refusal. Interview with Ombudsman confirms resident is refusing showers. R1 refused to speak with LPA. LPA toured the dining room CONTINUED ON LIC 9099C DATED 05/19/202
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20220511104605
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 306005949
VISIT DATE: 05/19/2022
NARRATIVE
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during the visit and observed meals served as well as posted menu. Menu has varied options for residents to choose from. Therefore the allegation is deemed UNFOUNDED, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2022
LIC9099 (FAS) - (06/04)
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