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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004637
Report Date: 03/28/2022
Date Signed: 03/28/2022 02:59:15 PM

Document Has Been Signed on 03/28/2022 02:59 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:SOLEIL SENIOR LIVINGFACILITY NUMBER:
306004637
ADMINISTRATOR:LISA GAITANFACILITY TYPE:
740
ADDRESS:23741 SINGAPORE STREETTELEPHONE:
(949) 716-7614
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY: 6CENSUS: 6DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator Scott BransonTIME COMPLETED:
03:15 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and was granted entry into the facility by Administrator. Upon entry LPA's temperature was checked. LPA observed a check in table upon entry which contained hand sanitizer, gloves, and masks,.LPA explained the reason for the visit.

LPA Tirre toured the facility at 1:45 PM with Administrator Scott Branson. Facility is a 5 bedroom 2 bathroom single story home. At time of visit there were six Residents in care. LPA observed residents relaxing in bedrooms watching TV. Residents appeared clean in appearance. LPA observed facility has required Department postings. Proper hand washing signs posted in facility restrooms. All restrooms observed contained working water basin, soap, hand sanitizer, toilet paper and hand towels. LPA observed locked areas for toxins and hazardous items. LPA toured Resident rooms, rooms where within regulations.



LPA observed Administrator certificate expiring January 10, 2023. Facility has 2 refrigerators and pantry with ample food supply. LPA observed facility has emergency food and water supply. Facility has 1 fire extinguisher which is mounted and fully charged. Facility has audible alarms for each entrance/exit doors. Facility has ample supply of PPE. Facility has a secured location for Resident medication and files. Facility has 30 days’ supply of medications for Residents. LPA reviewed 5 of 5 Resident files during visit. Resident emergency contact information and physician’s reports are current. Facility has designated visitation area.

No deficiencies noted during this visit. An exit interview was conducted with Administrator and a copy of report was left at facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
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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