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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006360
Report Date: 08/09/2023
Date Signed: 08/10/2023 08:39:58 AM


Document Has Been Signed on 08/10/2023 08:39 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:WATERMARK LAGUNA NIGUELFACILITY NUMBER:
306006360
ADMINISTRATOR:THARP, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:27762 FORBES ROADTELEPHONE:
(520) 797-4000
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:135CENSUS: DATE:
08/09/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Christopher Tharpe - AdministrationTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an announced visit to the facility for purpose of conducting a pre-licensing inspection. LPA arrived at the facility at 1:00pm and was greeted and granted entry by Administrator (AD) Christopher Tharpe. An application to operate a Residential Care Facility for Elderly (RCFE) for (135) capacity, (85) ambulatory, (68) non-ambulatory, and (12) bedridden clients was received by Community Care Licensing (CCL) on 05/30/2023.

Facility is a three story building housing with 78 Assisted Living single-occupancy apartments and 32 Memory Care apartments. 6 of the Memory Care apartments are shared occupancy. The facility also houses 2 courtyards, a living room on each floor, a bistro, 2 dining rooms, 2 community patios, Staff break room, a Med room on each floor, nurse office on the 3rd floor and a parking structure.

Resident Apartments: LPA observed model apartments with all the required furnishings. Per the facility’s admission agreement, Residents are encouraged to furnish their rooms. If Residents are unable to furnish their rooms, facility will order furnishings as needed.

Toxins: LPA observed chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored and locked in the kitchen and laundry rooms,

Medications, First-Aid Kit & Book: Medication will be stored in locked cabinets in the Med Room on each floor. The first aid kits have all the required elements.

Resident & Staff Files: Staff Records will be kept locked in the HR office on the 1st floor. Resident Records will be locked in a dedicated closet on the 3rd floor.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
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 COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WATERMARK LAGUNA NIGUEL
FACILITY NUMBER: 306006360
VISIT DATE: 08/09/2023
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Fire Extinguisher: LPA observed three fire extinguishers to be fully charged as indicated by the arrow pointing in the green zone. LPA observed the service tags indicating the Fire Extinguishers were last serviced on January 6, 2023.

Activities: The facility has activity materials that will be kept in the Activity Rooms on the second and third floors. Activity calendars were posted and available for review.

Fire clearance: Was approved by a fire inspector of Orange County Fire Authority on 07/28/2023.

Bathrooms: All bathrooms have working plumbing. Hot water in each unit measured between 105 and 120 degrees Fahrenheit.

Emergency Phone Numbers, Exit Plan & Menu: Posted and available for review.

Food Service: There is a supply of 7-day non-perishable food on hand.

Smoke Detectors: Smoke detectors were observed to be dual Smoke & Carbon Monoxide detectors that are stationed throughout the facility. The dual detectors were tested and observed to be operational. The facility also has fire doors on each floor.

Appliances: Kitchen appliances and laundry machines were observed to be operational.

The AD was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. Exit interview was conducted and a copy of this report was provided to designated AD.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023
LIC809 (FAS) - (06/04)
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