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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006042
Report Date: 12/16/2024
Date Signed: 12/17/2024 05:50:11 AM

Document Has Been Signed on 12/17/2024 05:50 AM - 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:DANA POINT MANORFACILITY NUMBER:
306006042
ADMINISTRATOR/
DIRECTOR:		DE LOS SANTOS, RAMILFACILITY TYPE:
740
ADDRESS:32591 SEVEN SEAS DRIVETELEPHONE:
(714) 227-6557
CITY:MONARCH BEACHSTATE: CAZIP CODE:
92629
CAPACITY: 6CENSUS: 5DATE:
12/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Susan Arevalo and Cristy ValerioTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Fred Arias conducted an unannounced visit to Dana Point Manor. The purpose of today’s visit was to conduct the annual required inspection. LPAs were allowed entry into the home and met with Caregiver Susan Arevalo and explained the reason for the visit. Assistant Administrator Cristy Valerio arrived shortly during the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 6 residents and the home currently has 5 residents, with 3 residents on hospice. Administrator Cybele Magtibay has an administrator certificate expiring on 07/03/2026. Upon entry, LPAs observed the medication closet opened and unsecured.

LPAs along with Assistant Administrator toured the facility at 7:46 AM. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 5 resident bedrooms, living room, dining room, and kitchen as well as 4 restrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 110.3 degrees F and 118 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. At 8:05 AM, LPAs observed the door to the garage was unlocked and toxins were unsecured. LPAs toured the kitchen at 8:15 AM and observed the burners on the cook top are only usable with the use of aim and flame lighters which were unsecured during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Medications were unsecured in the refrigerator. LPAs observed sharps as well as cleaning supplies locked under the sink. Kitchen appliances were operational during today's visit. Smoke detectors and carbon monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers were fully charged. LPAs reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 10/07/2024. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. CONTINUED ON LIC 809C DATED 12/16/2024.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: DANA POINT MANOR
FACILITY NUMBER: 306006042
VISIT DATE: 12/16/2024
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First aid kit contained all required items including tweezers, scissors and thermometer. Facility conducts activities in the form of music, exercise and arts and crafts. There is shaded outdoor seating for residents. Exit gates are unlocked and operational. LPAs observed the emergency food and water supply. LPAs reviewed five resident files and three staff files. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. Medications are stored in a locked closet. Medications are being administered per physician order.



Licensee has been asked to provide an updated LIC 500 (Personnel report), LIC 610 (Emergency Disaster Plan), and LIC 308 (Designation of Facility Responsibility) by 12/30/2024.

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/17/2024 05:50 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 12/16/2024 at 10:39 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: DANA POINT MANOR
FACILITY NUMBER: 306006042

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed unsecured toxins in the unlocked garage and unsecured "Aim and flame" lighters in the kitchen which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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Licensee to secure noted items and forward proof to LPA by POC due date.
Type A
Section Cited
CCR
87455(h)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above. LPAs observed unsecured medications in the unlocked medication closet as well as in the refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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Licensee to secure medications and forward proof to LPA by POC due date. Licensee secured items during the visit.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 12/17/2024 05:50 AM - It Cannot Be Edited


Created By: Kimberly Lyman On 12/16/2024 at 10:39 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: DANA POINT MANOR
FACILITY NUMBER: 306006042

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed 4 burners on the cook top that are not operational without a lighter and the electric outlet surrounding area in restroom is in need of repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2024
Plan of Correction
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Licensee to repair/ replace noted items and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2024


LIC809 (FAS) - (06/04)
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