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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006042
Report Date: 11/15/2022
Date Signed: 11/15/2022 11:06:45 AM


Document Has Been Signed on 11/15/2022 11:06 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:DANA POINT MANORFACILITY NUMBER:
306006042
ADMINISTRATOR:DE LOS SANTOS, RAMILFACILITY TYPE:
740
ADDRESS:32591 SEVEN SEAS DRIVETELEPHONE:
(714) 227-6557
CITY:MONARCH BEACHSTATE: CAZIP CODE:
92629
CAPACITY:6CENSUS: 5DATE:
11/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:52 AM
MET WITH:Sam Tan and Susan ArevaloTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Sam Tan and explained the reason for the visit. Administrators Ramil De Los Santos and Cristy Valero have submitted administrator certificate renewals and are awaiting response from the department.
At 9:12 AM, LPA toured the facility with Caregiver Arevalo. Facility has 5 residents present during today's visit with 2 on hospice care. Facility has covid precaution signage outside the facility. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility utilizes a visitor sign in sheet but does not document temperatures. Facility has covid precaution postings inside facility as well and facility provided proof of daily temperatures for staff and residents. LPA observed residents relaxing in the facility. LPA spoke with select residents and residents appeared happy and well taken care of. Facility appears clean and sanitary. Smoke detectors/ carbon monoxide detectors are hardwired and tested operational during today's visit. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer and paper towels. First aid kit has all required items including scissors and tweezers. LPA observed ample emergency food, water, and supplies. LPA toured the outside grounds and observed the shaded outside visitation area. Exit gates are unlocked and self latching. Garage is locked and toxins are secured. LPA toured the kitchen and observed ample food supply as well as operational appliances. Facility has a posted sample menu. Residents participate in activities such as exercise/ walking. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed select resident files during the visit and all files have updated emergency information. All residents and staff are vaccinated for Covid-19.
LPA consulted with Caregiver regarding the importance of documenting temperatures for all visitors in the facility as well as ensuring all facility restrooms have hand washing signs posted.
Based on the observations made from today's visit, NO deficiencies are being cited. 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: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
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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