306006203-11-3-2022-22-AS-JALE-CKTS85-20221103133833

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006203
Report Date: 11/03/2022
Date Signed: 11/03/2022 01:38:41 PM

Document Has Been Signed on 11/03/2022 01:38 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:	IVY PARK AT SAN JUAN CAPISTRANO		FACILITY NUMBER:	306006203
ADMINISTRATOR:	MENSAH, ERIC		FACILITY TYPE:	740
ADDRESS:	32200 DEL OBISPO STREET		TELEPHONE:	(949) 496-8802
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY:	120	CENSUS: 46	DATE:	11/03/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Eric Mensah, Daniel Lines		TIME COMPLETED:	02:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Joseph Alejandre made an announced visit to conduct the pre-licensing inspection. LPA was screened for symptoms of Covid-19 and granted entry. LPA met with Executive Director (ED) Eric Mensah and Administrator Daniel Lines. LPA explained the reason for the visit. An application to operate a Residential Care Facility for the Elderly (RCFE) for a capacity of 116 non-ambulatory residents and 4 bedridden residents for a total capacity of 120 residents and hospice waiver for 15 was submitted to Community Care Licensing (CCL), the application is dated 10/05/2022. Structure: The facility is a two story building with 54 resident rooms on the first floor and 43 resident rooms on the second floor. The first floor has two large living rooms, dining room, activity room and an outdoor garden courtyard with a fountain. The fountain is raised and does not present a hazard to residents. Outside of the dining room there is an outdoor promenade with tables and chairs for residents to sit outside. Facility telephone phone number is 949-496-8802. LPA observed the See Something, Say Something poster (PUB 475) in the main entrance of the facility. LPA observed the Ombudsman poster with address and phone number of the local Ombudsman posted in the activity room on the first floor. Facility does not have any delayed egress exits. Facility does not have a memory care unit. Resident rooms Resident rooms are private rooms which have a closet, bathroom and kitchenette. Residents move in with their own furnishings but the facility will provide the required furnishings, bed, night stand, lamp, chair and a chest of drawers if residents require it. Signal system The signal system operates from each resident room and common bathroom. The signal system is operational and meets the regulatory requirements.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: IVY PARK AT SAN JUAN CAPISTRANO	FACILITY NUMBER: 306006203
	VISIT DATE: 11/03/2022

NARRATIVE

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Bathrooms:
All bathrooms have working plumbing. LPA observed the common bathrooms to be clean and operational. LPA measured the hot water in room number 108 and the common bathrooms to be 119.0 degrees Fahrenheit.

Linens & Hygiene Supplies:
Adequate supply of linen and cleaning supplies stored in the supply closets.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one month prior and listed for food served for one month. Emergency food and water supply is stored in a storage room.

Food Service:
LPA observed the kitchen is clean and organized. The freezer and refrigerator are at the required temperatures. LPA observed a 2 day perishable food supply and a 7 day non-perishable food supply on hand in the kitchen pantry.

Smoke Detectors:
Smoke detectors and carbon monoxide detectors are operational. The fire sprinkler system is maintained by a third party vendor.

Toxins:
All toxic chemicals, cleaning solutions, laundry toxins and disinfectants used by the facility are stored in locked storage rooms/closets and inaccessible to residents.

Medications, First-Aid Kit & Book:
Medication will be stored in the locked medication room on the first floor. There is a first aid kit in the medication room and they are located throughout the facility.

Resident & Staff Files:
Records will be kept secured in the facility offices.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: IVY PARK AT SAN JUAN CAPISTRANO	FACILITY NUMBER: 306006203
	VISIT DATE: 11/03/2022

NARRATIVE

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Pool/Jacuzzi & Pets:
No pools or hot tubs at the facility. There are two fountains at the facility one in the garden courtyard and one by the front entrance. Both fountains are raised and do not pose a hazard to visitors or residents. Residents are allowed to keep small pets in their room as agreed upon in their admission agreement.

Fire Extinguisher:
All facility fire extinguishers are fully charged.

Reading Material, Games, Equipment & Materials:
The facility has numerous supplies for activities including supplies for arts and crafts, board games, books and a large TV in the theater room on the second floor. The activity calendar is posted in the first floor lobby for the current month.

Fire clearance:
Was approved by Orange County Fire Authority inspector Nathan Bobbitt on 9/6/2022. Fire clearance is approved for 116 non-ambulatory residents and 4 bedridden residents for a total capacity of 120. Delayed egress exits are not approved.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance and reporting requirements.

The Executive Director and the Administrator were notified that the final application approval will be issued by the Centralized Applications Bureau (CAB) in Sacramento. LPA informed the Executive Director and Administrator that once the facility is licensed a post licensing visit will be conducted within 90 days of licensure. LPA did not observe any obstacles or hazards inside or outside of the facility. No deficiencies observed during the visit. The facility meets Title 22 requirements and is ready to be licensed. Exit interview was conducted and a copy of this report was provided to the Executive Director.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph Alejandre	TELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022

LIC809 (FAS) - (06/04)

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