306006717-7-28-2025-22-AS-JALE-DJZQ63-20250728115253

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006717
Report Date: 07/28/2025
Date Signed: 07/28/2025 11:53:00 AM

Document Has Been Signed on 07/28/2025 11:53 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ADAGIO SAN JUAN		FACILITY NUMBER:	306006717
ADMINISTRATOR/ DIRECTOR:	ZUEHL, HERMINIA H		FACILITY TYPE:	740
ADDRESS:	31822 SAN JUAN CREEK CIRCLE		TELEPHONE:	(949) 388-9219
CITY:	SAN JUAN CAPISTRANO	STATE: CA	ZIP CODE:	92675
CAPACITY: 6		CENSUS: 5	DATE:	07/28/2025
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Herminia Zuehl		TIME VISIT/ INSPECTION COMPLETED:	11:52 AM

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 met with applicant Herminia Zuehl. An initial application to operate a Residential Care Facility for the Elderly (RCFE) for 6 non-ambulatory residents of which 3 can be bedridden was submitted to Community Care Licensing (CCL) on February 10, 2025. Facility requested a hospice waiver for 6. Facility phone number 949-388-9219. Structure. The facility is a one story house with 6 bedrooms, 3 bathrooms, living room, kitchen, dining room, laundry room and an attached 2 car garage. LPA observed the fire extinguisher in the kitchen is fully charged. LPA observed the fireplace in the living room is screened. The key that operates the fireplace is kept locked. LPA observed the See Something, Say Something sign (PUB 475) posted next to the front door. Resident rooms. LPA observed all the resident rooms have the required furnishings and bed linens. LPA observed there is a TV in the living room with 3 chairs, a sofa and a loveseat. LPA observed extra linens store in the hallway linen closet. Bathrooms. Facility has 3 bathrooms and all bathrooms are clean and operational. Water Temperature. LPA measured the hot water at 114.9 degrees Fahrenheit in all bathrooms Emergency Phone Numbers & Exit Plan. LPA observed Personal Rights of Residents posted along with, the Facility's Theft and Loss Policy, Rights of Resident Councils and the Emergency Disaster plan, which contains emergency phone numbers for first responders. The facility sketch showing all emergency exits and exit routes is posted throughout the facility. Appliances. LPA observed the stove, oven and refrigerator are all clean and operational. The 5 burner gas stove lights unassisted. The washer and dryer in the laundry room and are clean and operational. Extra cleaning supplies are kept locked in cabinets in the laundry room.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: ADAGIO SAN JUAN	FACILITY NUMBER: 306006717
	VISIT DATE: 07/28/2025

NARRATIVE

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Food Service. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. LPA observed a 3 day emergency supply of food and water stored in the garage. The garage is kept locked and used for storage. Toxins and cleaning supplies are kept locked in the hall closet. Clients & Staff Files are kept locked in a kitchen cabinet. Medications are kept locked in the medication closet in the living room. First-Aid Kit & Book are kept locked in medication closet. LPA observed the first aid kit has all the required elements. Reading Material, Games, Equipment & Materials. Reading materials and games are kept in the living room.

Fire clearance, the fire clearance was approved by Orange County Fire Authority on April 8, 2025. Backyard No bodies of water observed. There is a table with an umbrella and chairs for residents to sit outside. The exit gate is operational and self closing. No obstacles or hazards observed in the backyard. Smoke Detectors/Carbon monoxide detectors tested operational. Component III: Waived, applicant is the owner/operator of other licensed facilities. No obstacles or hazards observed inside or outside of the facility. Facility has an internet device (Tablet) dedicated for resident use only. LPA observed the front door and sliding door in the dining room have alarms and sound when opened. No deficiencies observed during the visit.

The facility is ready to be licensed. LPA informed the applicant that final approval for licensure will be approved by CAB (Central Applications Bureau) in Sacramento. Applicant stated they understood.
Exit interview was conducted and a copy of this report was provided to the applicant.

NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Joseph Alejandre
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025

LIC809 (FAS) - (06/04)

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