374604508-3-23-2022-18-AS-SMAZ-CCSV3B-20220323160424

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604508
Report Date: 03/23/2022
Date Signed: 03/23/2022 04:05:32 PM

Document Has Been Signed on 03/23/2022 04:05 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
CCLD Regional Office,
, CA

FACILITY NAME:	ESTANCIA SENIOR LIVING		FACILITY NUMBER:	374604508
ADMINISTRATOR:	SMITH, LAWRENCE		FACILITY TYPE:	740
ADDRESS:	1735 SO MISSION ROAD		TELEPHONE:	(240) 595-6061
CITY:	FALLBROOK	STATE: CA	ZIP CODE:	92028
CAPACITY:	128	CENSUS: 41	DATE:	03/23/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Adminiatrator, Lawrence Smith, Regional Nurse Christina Harris		TIME COMPLETED:	03:10 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) Sabel Martinez, conducted a scheduled Pre-Licensing inspection to observe the physical plant for compliance, and conduct a Component III. The facility is in a change of ownership process. The fire department completed their inspection on 10/19/2021. Facility is approved for a capacity of One hundred twenty-eight (128) residents. LPA was greeted by Administrator, Lawrence Smith, and Regional Nurse, Christina Harris, to whom the purpose of the visit was disclosed. An overall tour of the facility was conducted inside and out. The inspection included, but was not limited to, verifying compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices. The LPA observed locked centrally stored medications for residents in care, perishable and nonperishable food requirements, available personal storage space for residents, and leisure activity space as well. The following infection control practices were observed; One central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; Signs throughout the facility to promote hand hygiene, cough/sneeze etiquette and physical distancing; face coverings worn by staff and residents; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of Personal Protective Equipment (PPE) . The facility is in compliance with and has implemented infection control practices as outlined in its LIC 808. The LPA, Administartor, and Regional Nurse discussed continuing operation requirements, record keeping, reporting requirement and physical plant compliance.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

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
CCLD Regional Office,
, CA

FACILITY NAME: ESTANCIA SENIOR LIVING	FACILITY NUMBER: 374604508
	VISIT DATE: 03/23/2022

NARRATIVE

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The Pre-licensing and Component III were completed on today's date. Facility is ready for Licensure pending management approval. This is a change of ownership application and there are forty one (41) residents currently in care. An exit interview was conducted with Administrator, Lawrence Smith, and Regional Nurse, Christina Harris, to whom a copy of this report along with Applicant/Appeal Rights (LIC9058 01/16) were provided via electronic mail. An electronic mail read receipt confirms the documents were received.

SUPERVISOR'S NAME: Simon Jacob	TELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel Martinez	TELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC809 (FAS) - (06/04)

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