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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004272
Report Date: 04/05/2022
Date Signed: 04/05/2022 03:31:30 PM

Document Has Been Signed on 04/05/2022 03:31 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CALIFORNIA LIFESTYLES IVFACILITY NUMBER:
306004272
ADMINISTRATOR:ROY OR SHEILA MOELLERFACILITY TYPE:
740
ADDRESS:715 CALLE AMABLETELEPHONE:
(949) 388-7390
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92673
CAPACITY: 6CENSUS: 6DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:53 AM
MET WITH:Roy Moeller and Luna FloresTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Administrator Roy Moeller and explained the reason for the visit. Administrator Roy Moeller has an administrator certificate expiring on 10/21/2023.

At 11:05 AM, LPA toured the facility with Administrator Moeller. Facility has six residents in care during today's visit, with one on hospice care. LPA observed residents relaxing in the facility. All residents appeared well taken care of. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Hand washing sign is posted in the common restroom. LPA observed the screening station in the entrance of the facility. Facility has covid precaution postings as well as all required department postings. LPA toured the kitchen and observed ample food supply. Facility has completed the mitigation plan and plan has been approved. LPA observed emergency food and water as well as the first aid kit which contained all required items. Facility has a generator for power outages. Smoke detector tested operational and fire extinguisher is mounted and charged. LPA toured the outside grounds and observed the outside visitation area. Exit gates are unlocked and self latching. Residents participate in activities such as exercise, puzzles, and games. LPA observed the locked medication storage area and facility utilizes a medication administration record. Facility has ample supple of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. All staff and residents are vaccinated for Covid-19. LPA reviewed all files which contained all required documentation including emergency information and physician reports.
LPA consulted with Administrator regarding the importance of documenting daily temperature taking of residents and staff. Additionally, LPA advised licensee on the importance of adding a health questionnaire onto the sign in sheet.
No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2022
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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