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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005949
Report Date: 09/21/2021
Date Signed: 09/21/2021 02:31:30 PM

Document Has Been Signed on 09/21/2021 02:31 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:CAPISTRANO SENIOR LIVINGFACILITY NUMBER:
306005949
ADMINISTRATOR:GARCIA, CYNTHIAFACILITY TYPE:
741
ADDRESS:31741 RANCHO VIEJO ROADTELEPHONE:
(844) 375-0029
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 125CENSUS: 66DATE:
09/21/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ninad DadabhoyTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced case management visit to follow up on an incident report submitted to licensing on 9/20/2021. LPA met with Health & Wellness Director and explained the reason for the visit.

Incident report dated 09/15/2021 indicated at 6:00 pm Resident 1 (R1) was found outside the facility by an unidentified person at the business park next door to the facility. The front desk was notified and staff contacted the med tech on duty. The med tech went next door and escorted the resident back to the facility. R1 was assessed and no injuries noted. Per physician report dated 07/21/2021, R1 is diagnosed with Dementia. R1's primary care physician (PCP) and responsible party (RP) were notified. Health & Wellness Director reported R1 was gone from the facility for approximately 10 minutes. Facility delayed egress system is operational. Health & Wellness Director reported that at the time of R1's elopement there was no staff next to the door and staff did not hear the alarm so no one responded to the door alarm.

Based on the information provided during today’s visit, the following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report along with appeal rights was provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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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Document Has Been Signed on 09/21/2021 02:31 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 09/21/2021 at 11:51 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CAPISTRANO SENIOR LIVING
FACILITY NUMBER: 306005949

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2021
Section Cited
CCR
87464(f)(1)

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Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirement is not being met as evidenced by:
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Licensee to provide a written, detailed plan to prevent the elopement of residents, including, provide an in-service training on elopement protocols and forward proof to LPA by POC due date.
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Based on interview and record review, Licensee did not ensure care and supervision was provided to Resident 1. R1 eloped from the facility on 9/15/2021 because staff did not respond to the door alarm. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Luz Adams
LICENSING EVALUATOR NAME:Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021


LIC809 (FAS) - (06/04)
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