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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604717
Report Date: 08/01/2024
Date Signed: 08/01/2024 02:56:27 PM

Document Has Been Signed on 08/01/2024 02:56 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HACIENDA MISSION SAN LUIS REY, THEFACILITY NUMBER:
374604717
ADMINISTRATOR/
DIRECTOR:		BUHLE, DIANEFACILITY TYPE:
740
ADDRESS:4000 MISSION AVETELEPHONE:
(520) 797-4000
CITY:OCEANSIDESTATE: CAZIP CODE:
92057
CAPACITY: 294CENSUS: 142DATE:
08/01/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Resident Care Director Carri CollinsTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Annual Continuation visit to continue the annual inspection started on 7/22/2024. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Resident Care Director Carri Collins.

The facility is licensed for a maximum capacity of 294 residents, 250 of which may be non-ambulatory and 12 may be bedridden in any room. The facility has a waiver for 25 hospice residents. During today’s visit, the facility had a census of 142 residents. The Administrator for the facility is Mariano Perez and their certificate was valid and current.

During visits on 7/22/24 and 8/1/24, LPA toured the facility and inspected a random sampling of resident rooms, common and private bathrooms, kitchen, common areas, and outside space. LPA observed a fenced pool in the assisted living portion of the facility which was secured by fencing and a locked gate which met regulation requirements. LPA observed delayed egress in the facility's memory care which matches the fire clearance approval. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 109.8, 110.7, 111.4, 111.7, 112.8, 113.0 and 113.8 degrees Fahrenheit in a random sampling of resident bathrooms. The facility’s internal temperature was measured at 71, 72, and 74 degrees Fahrenheit at different locations of the facility during the walk through. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. According to Carri Collins, no firearms or weapons are stored on the premises. LPA also observed locked storage for resident medications and resident and staff files. Resident medications are stored in their original container and labelled. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 39 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit.
Continued on LIC809-C page…
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HACIENDA MISSION SAN LUIS REY, THE
FACILITY NUMBER: 374604717
VISIT DATE: 08/01/2024
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LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance and were associated to the facility. LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and residents present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

The Executive Director will submit copies of the LIC500 Personnel Report, LIC610 Disaster Plan, and current liability insurance to the Department within 15 business days.

No deficiencies were cited on today’s date. An exit interview was conducted with Executive Director Mariano Perez via telephone and Resident Care Director Carri Collins, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 3/22).
SUPERVISORS NAME: Jennifer Lott
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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