306006248-5-22-2023-22-AS-RMAZ-CS3SVX-20230522141327

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006248
Report Date: 05/22/2023
Date Signed: 05/22/2023 03:59:58 PM

Document Has Been Signed on 05/22/2023 03:59 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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	MORNINGSTAR SENIOR LIVING OF MISSION VIEJO		FACILITY NUMBER:	306006248
ADMINISTRATOR:	SUMMERELL, DYAN		FACILITY TYPE:	740
ADDRESS:	28570 MARGUERITE PARKWAY		TELEPHONE:	(949) 649-4855
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92692
CAPACITY:	198	CENSUS: 0	DATE:	05/22/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Dyan Summerell		TIME COMPLETED:	02:40 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) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at facility was greeted and granted entry. LPA met with Dyan Summerell, Director/Administrator and discussed the visit. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (198) capacity, (76) ambulatory, (0) non-ambulatory, and (122) bedridden resident was submitted to CCL on October 14, 2022. Structure: The facility is a three-story building with underground parking with 132 resident apartment style bedrooms, first floor common spaces are: dining room, kitchen, fitness center, beauty salon, library, bistro, club room/theater, physical therapy room, spa room, and art studio. Second floor common spaces are: med room, dining room, and living room. Third floor common space is billiard/game room. Facility has a memory care unit that has 30 apartment style bedrooms. The laundry unit is in the basement and all assisted living apartments have their own washer and dryer. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There are two courtyards one only for memory care unit and one for assisted living with a gated pool, there is several seating areas for resident and several patios with seating for residents. Signal system: Delayed Egress System in place in memory care unit. Signal system for pendants/call buttons that are in place in each apartment in memory care and assisted living. Continued on LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MORNINGSTAR SENIOR LIVING OF MISSION VIEJO	FACILITY NUMBER: 306006248
	VISIT DATE: 05/22/2023

NARRATIVE

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Air/Heating:
Central air/heating system installed with a central panel to control entire building.

Bedrooms Residents:
Bedrooms are apartment style that will be private or shared.

Bedrooms Staff:
Designated bedroom for live-in staff, there is a designated staff lounge.

Bathrooms:
All bathrooms have a working toilet, wash basin, walk in shower/tub. There is common restrooms and each apartment has its own bathroom.

Linens & Hygiene Supplies:
Facility has an adequate supply of linens in storage unit.

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 week prior and listed for food serve for one week.

Food Service:
Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen with surplus good storage is in basement unit.

Smoke Detectors:
Smoke detectors, sprinklers and carbon monoxide alert systems are tested and maintained by an outside vendor. Fire extinguishers mounted throughout the facility charged with a date of November 03, 2022.

Continued on LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

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
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MORNINGSTAR SENIOR LIVING OF MISSION VIEJO	FACILITY NUMBER: 306006248
	VISIT DATE: 05/22/2023

NARRATIVE

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Appliances:
Residents’ apartments have small kitchen, electric stove, refrigerator, microwave and small sink. Facility main kitchen on the 1^st floor is equipped with ovens/ranges/microwaves, prep counters, refrigeration, freezer, grill, steam tables, ice makers, there are washer and dryers in the laundry unit as well as in each apartment and are clean and noted to be operational.

Toxins:
All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored in housekeeping storage units.

Water Temperature:
Tested and recorded maintained at a comfortable temperature and the water temperature measures between 112.2 – 119.8 Fahrenheit degrees in facility bathrooms.

Medications, First-Aid Kit & Book:
Medication, first aid and book are stored in med room inaccessible to residents. First aid kits are also located in med carts.

Resident & Staff Files
Records will be kept stored electronically on site.

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation.

Fire clearance:
Was approved on April 20, 2023. Bedridden only on floors one and two, delayed egress in memory care in three locations. All ambulatory in third floor.

Continued on LIC809-C

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MORNINGSTAR SENIOR LIVING OF MISSION VIEJO	FACILITY NUMBER: 306006248
	VISIT DATE: 05/22/2023

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 26 27 28 29 30 31 32	Component III: Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance. Facility appears to be ready for licensure. Accordingly, LPA will submit file for approval to CCL Supervisor. Exit interview was conducted and a copy of this report was left with the applicant.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth Martinez	TELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023

LIC809 (FAS) - (06/04)

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