374604717-8-16-2023-08-AS-DNGN-CURSHH-20230816135334

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604717
Report Date: 08/16/2023
Date Signed: 08/16/2023 01:53:55 PM

Document Has Been Signed on 08/16/2023 01:53 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	HACIENDA MISSION SAN LUIS REY, THE		FACILITY NUMBER:	374604717
ADMINISTRATOR:	PEREZ, MARIANO		FACILITY TYPE:	740
ADDRESS:	4000 MISSION AVE		TELEPHONE:	(520) 797-4000
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY: 294		CENSUS: 0	DATE:	08/16/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Licensee's Representatives, Executive Director Mariano Perez, Regional Director of Health Services Shawn Gray, Managing Director Olga Rey-Kirksey, and Plant Operations Director David Hernandez		TIME COMPLETED:	02:15 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) Dang Nguyen conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to the applicant’s representatives, Executive Director Mariano Perez, Regional Director of Health Services Shawn Gray, Managing Director Olga Rey-Kirksey, and Plant Operations Director David Hernandez. The facility fire clearance was granted on 07/06/2023 and reflects that the facility was approved for 294 residents in total, of which 250 may be non-ambulatory and 12 may be bedridden. The facility's fire clearance included approval for delayed-egress doors in facility's memory care section, and LPA found that these doors were complaint. The facility's fire clearance did not include endorsement for secured perimeter, and this was not present during today's visit. During today’s visit, LPA, accompanied by the applicant’s representatives, toured the interior and exterior of the facility and inspected bedrooms and common areas. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets, sinks, and showers were in working order. The facility’s ambient internal temperature was compliant at 72 degrees F. Hot water temperature at taps accessible to residents were also compliant: Room #1108 sink was 113.4 F, Room #1116 sink was 112.6 F, Room #1250 sink was 112.3 F, Room #1341 sink was 111.4 F, Room #2110 sink was 110.5 F, Room #2126 sink was 111.6 F, Room #2137 sink was 112.8 F, Room #2222 sink was 111.6 F, Room #3102 sink was 111.7 F, Room #3118 sink was 108.3 F, Room #3124 sink was 111.6 F, and Room #3147 sink was 110.8 F. The submitted facility sketch was consistent with the current layout of the facility. [CONTINUED ON LIC 809-C]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HACIENDA MISSION SAN LUIS REY, THE	FACILITY NUMBER: 374604717
	VISIT DATE: 08/16/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food for future resident use. All kitchen appliances were in working order. Refrigerator temperatures were compliant at 38 F, 35 F, 37 F, 38 F, 39 F, and 37 F, respectively. Temperature in each of the facility's freezers was 0 F.

The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of medication and confidential resident and staff records. The facility's swimming pool was secured behind a fence and locking gates which meet regulatory requirements.

There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant’s representatives, no firearms or ammunition are or will be stored at the facility.

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. Fire extinguisher were serviced within the last 12 months. Complete first aid kits were present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. The applicant passed the pre-licensing inspection.

LPA also provided the Component III Training during today’s visit. The applicant's representatives were advised that the facility’s application is pending management final review and approval.

An exit interview was conducted with the applicant’s representative, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2023

LIC809 (FAS) - (06/04)

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