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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005949
Report Date: 07/21/2022
Date Signed: 07/21/2022 02:52:38 PM


Document Has Been Signed on 07/21/2022 02:52 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:BRYAN HADLEYFACILITY TYPE:
741
ADDRESS:31741 RANCHO VIEJO ROADTELEPHONE:
(844) 375-0029
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:125CENSUS: 92DATE:
07/21/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:51 PM
MET WITH:Executive Director Byan Hadley TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Albert Marin and Celine De Perio conducted an unannounced case management visit to this facility. LPAs met with Executive Director (ED) Bryan Hadley and stated the purpose of this visit.

After interview with ED Hadley, LPAs Marin and De Perio a tour in memory care unit of the facility. LPAs observed rooms of identified residents with information posters and infection control cart available by the door. Per ED, all community and group activities were suspended. Facility were using disposable utensils for meal preparation. Notices were also available in common areas.

LPAs Marin and De Perio provided consultation with ED Hadley regarding the reporting requirements. LPAs provided ED with the document describing the information needed by Community Care Licensing Division (CCLD) Orange Office to review and process the reports. LPAs also provided directions to ED to send all incident reports and general correspondence to CCLD Orange Office general email address: CCLASCPOrangeCountyRO@dss.ca.gov

LPAs requested copy of staff roster and provided consultation with ED Hadley regarding the Guardian System.

For this visit, no citation was issued at this time.

LPAs Marin and De Perio conducted an exit interview with ED Hadley and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022
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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