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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006360
Report Date: 08/12/2024
Date Signed: 08/12/2024 01:57:05 PM


Document Has Been Signed on 08/12/2024 01:57 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 COUNTY RO, 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:
(949) 899-8175
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:135CENSUS: 42DATE:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lee KaufmannTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Managing Director Lee Kaufmann and explained the reason for the visit. LPA and the Managing Director toured the facility.

Facility is a three story building with 78 Assisted Living resident rooms and 38 Memory Care resident rooms. 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 and a parking structure.

LPA observed the memory care has a secured perimeter and delayed egress. The delayed egress exits are operational. The memory care is on the first floor and has a dining area, activity room and outdoor patio with shaded seating. LPA toured the resident rooms in memory care. The resident rooms toured had all the required furnishings. The smoke detectors tested operational. There is an activity room with puzzles and games along arts and crafts supplies. There is a Large screen TV mounted on the wall in the activity room. No obstacles or hazards observed in the memory care.

LPA the Managing Director toured the assisted living which is on the second and third floors. LPA observed each stairway has an emergency evacuation chair. LPA observed the kitchen is clean and organized. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The emergency food and water supply is stored in a storage room. LPA observed the refrigerators and freezer are at the required temperatures. The resident rooms inspected in assisted living have the required furnishings. Hot water measured 112.0 degrees Fahrenheit in resident bathrooms. All bathrooms inspected are clean and operational. There are activity rooms with games and reading materials on the second and third floor. Each activity room has a large screen TV.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WATERMARK LAGUNA NIGUEL
FACILITY NUMBER: 306006360
VISIT DATE: 08/12/2024
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The assisted living section has a courtyard on the first floor with shaded seating. No bodies of water observed. There is also shaded balconies on the second and third floor for assisted living residents. No obstacles or hazards observed in the assisted living section.

The last emergency drill took place on July 9, 2024. LPA observed the medication are kept locked in the medication room on the second floor and in the medication room on the first floor in memory care. LPA reviewed 4 resident medications, no discrepancies observed.

LPA reviewed 5 resident files, no discrepancies observed. LPA reviewed 5 staff files. All staff had the required training. No discrepancies observed. Staff members present are background cleared and associated to the facility.

No deficiencies observed during the inspection. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024
LIC809 (FAS) - (06/04)
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