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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006591
Report Date: 01/15/2025
Date Signed: 01/15/2025 04:28:03 PM

Document Has Been Signed on 01/15/2025 04:28 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:KATELLA SENIOR LIVING COMMUNITYFACILITY NUMBER:
306006591
ADMINISTRATOR/
DIRECTOR:		PERALEZ, JONFACILITY TYPE:
740
ADDRESS:3952 KATELLA AVETELEPHONE:
(562) 596-2773
CITY:LOS ALAMITOSSTATE: CAZIP CODE:
90720
CAPACITY: 140CENSUS: 51DATE:
01/15/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Executive Director Jon PeralezTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analysts (LPA's) Jenifer Tirre and Eboni Bentley made an announced pre-licensing visit. LPA's identified themselves and discussed the purpose of the visit with Ensign Services Assisted Living Resource Eric Terrill, Ensign Licensing Manager Kristin Osuna-Larson, Ensign Services Director of Licensing and Regulatory Services Soon Burnam, Executive Director Jon Peralez, Wellness Director Michelle Drinkard, and Life & Safety Resources Eduardo Rivas. Visit is a change in ownership with residents in care. An initial application to operate a Residential Facility Care for the Elderly was submitted to CCL on May 9, 2024. There are 51 residents in care during today's visit.

LPA's Tirre and Bentley along with Ensign Services Assisted Living Resource Eric Terrill, Ensign Licensing Manager Christina Osuna-Larson, Ensign Services Director of Licensing and Regulatory Services Soon Burnam, Executive Director Jon Peralez, Wellness Director Michelle Drinkard, Life & Safety Resources Eduardo Rivas toured the facility at 8:15 AM and observed the following:
Structure: Facility is a two story building housing 70 apartments (57 apartments in the assisted living and 13 apartments in the memory care unit). Facility offers a library, dining room, activities area as well as two outside courtyards. Living Room/ Dining Room: Adequate seating is available in the main dining room. Bedrooms Residents: All rooms observed are equipped with appropriate lighting, chair, night stand and ample closet space. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Facility has ample perishable and non perishable food supplies. LPA's observed a posted menu with multiple choices for residents. Smoke Detectors: Carbon monoxide detectors were are operational. Smoke detectors are tested in-house and documentation was provided by Thunder Fire. Fire extinguishers observed were mounted and fully charged. During todays visit 12 extinguisher's were observed. Toxins: Secured and inaccessible to residents in care. Water Temperature: Tested and recorded between 112.6 and 118.7 degrees F in tested bathrooms. During todays visit 10 restrooms were observed. Emergency Supplies: LPA observed ample emergency food and water stored onsite in facility storage. CONT ON LIC 809C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/15/2025
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: KATELLA SENIOR LIVING COMMUNITY
FACILITY NUMBER: 306006591
VISIT DATE: 01/15/2025
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LPA's observed the emergency disaster plan and facility has submitted Infection Control Plan as well.Medications, First-Aid Kit & Book: LPA's observed first aid kit has contained required elements. Medications are stored in locked medication carts. Facility uses electronic medication administration record. Resident & Staff File: LPA's reviewed eight staff personnel files and eight resident files during the visit. All files were complete. Reading Material, Games, and Equipment: LPA's observed facility library room with reading material, activities area located in dining room had ample supplies of games, exercise equipment and craft supplies. Activities were posted in multiple locations. Outside areas: LPA observed three outside courtyard areas (two in Assisted living and one in Memory Care) with shaded areas, water fountains and garden. Fire Clearance: Approved for 140 non-ambulatory residents on November 12, 2024. LPA's observed two emergency chairs adjacent to facility staircases.

Administrator's Certificate on file for Jon Peralez effective 8/21/2023 - 8/20/2025, Facility has Liability Insurance on file effective 1/1/2025 - 1/1/2026.

Component III was conducted during visit. Facility is ready to be licensed. Exit interview conducted with Ensign Services Representatives Eric Terrill, Soon Burnam, Eduardo Rives and Katella Senior Living Executive Director Jon Peralez, and Wellness Director Michelle Drinkard. A copy of this report was provided to the facility.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2025
LIC809 (FAS) - (06/04)
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