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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306005949
Report Date:
06/07/2022
Date Signed:
06/07/2022 10:27:09 AM
Document Has Been Signed on
06/07/2022 10:27 AM
- 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 LIVING
FACILITY NUMBER:
306005949
ADMINISTRATOR:
GARCIA, CYNTHIA
FACILITY TYPE:
741
ADDRESS:
31741 RANCHO VIEJO ROAD
TELEPHONE:
(844) 375-0029
CITY:
SAN JUAN CAPISTRANO
STATE:
CA
ZIP CODE:
92675
CAPACITY:
125
CENSUS:
92
DATE:
06/07/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
08:35 AM
MET WITH:
Brian Hadley
TIME COMPLETED:
10:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA met with Executive Director Brian Hadley. LPA explained the reason for the visit. LPA and executive director toured the facility. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and 7 day non perishable food supply on hand. Facility has a emergency water and food supply. The dining room is clean and has enough space to accommodate the residents. Facility has a 30 day supply of PPE. LPA observed all staff was wearing masks. LPA observed hand sanitizing stations in the facility. LPA toured the memory care section of the facility. LPA observed residents participating in activities with the staff. LPA observed the medications are kept in carts and the carts are secured in the med room. LPA observed all fire extinguishers are fully charged. No obstacles or hazards observed inside or outside of the facility. LPA observed an emergency chair lift in each stairwell. LPA consulted with the executive director concerning continued Covid-19 mitigation and reporting requirements. 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 Adams
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Joseph Alejandre
TELEPHONE:
(951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE:
06/07/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/07/2022
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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