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Inspection visit

Routine inspection

CAPISTRANO SENIOR LIVINGLicense 3060059491 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by staff. LPA met with Executive Director Bryan Hadley and explained the reason for the visit. Bryan Hadley's Administrator's certificate expires on February 3, 2027. Facility is a two story building with 114 resident rooms which includes a memory care unit. Facility is approved for delayed egress exits in the memory care unit. Facility is licensed for 125 non-ambulatory residents with a hospice waiver for 25. LPA and the Executive Director (ED) toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entrance. LPA and the ED toured the kitchen and dining room. LPA observed the kitchen is clean and organized. There is a two day supply of perishable food and a seven day supply of non-perishable food on-hand in the kitchen. The refrigerators and freezers were at the required temperatures. LPA observed temperature logs posted on the refrigerator. LPA observed a 3 day emergency food supply stored in a supply closet. LPA observed a 3 day emergency water supply stored outside next to the courtyard. There is a courtyard outside the dining room in assisted living. The courtyard has shaded seating to sit outside and a fountain. LPA and ED toured 10 resident rooms on the first and second floors. All resident rooms had the required furnishings and bed linens. All resident bathrooms were clean and operational. The hot water in the resident rooms inspected measured 111.0 degrees Fahrenheit to 116.9 degrees Fahrenheit. There is a library next to the dining room with games and puzzles and a TV room for residents. During the visit residents were participating in a music activity in the great room next to the library. LPA observed all the fire extinguishers throughout the facility were fully charged. The facility has 4 stairwells. LPA observed an emergency evacuation chair at the top of each stairwell. LPA observed the facility has a desktop computer with internet access for dedicated resident use in the activity room. The last emergency drill was conducted on April 25, 2025. LPA and ED toured the memory care unit. LPA observed the resident rooms in memory care had the required furnishings and bed linens. There is an outdoor patio/courtyard in memory care with shaded seating for residents to sit outside. There is a delayed egress exit in the memory care patio/courtyard. All of the delayed egress exits in memory care tested operational. LPA observed medications are kept secured in a medication cart that is locked in the medication room. The first aid kit in the medication room has all the required elements. LPA interviewed staff and residents. LPA reviewed 5 staff files. LPA observed all 5 staff had more than 20 hours of annual training but did not have 4 hours of training for postural supports, restricted health conditions and hospice care. No other discrepancies observed. The staff, whose files were reviewed and the staff who were interviewed are all background cleared and associated to the facility. LPA reviewed 10 resident files, no discrepancies observed. LPA inspected resident medications, no discrepancies observed. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.

Citations

1 citation recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 1569.625(b)(2)Type B

    Based on record review, the licensee did not comply with the section cited above in 5 out of staff files which poses a potential health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the June 18, 2025 inspection of CAPISTRANO SENIOR LIVING?

This was a inspection inspection of CAPISTRANO SENIOR LIVING on June 18, 2025. 1 citation were issued: 1 Type B.

Were any citations issued to CAPISTRANO SENIOR LIVING on June 18, 2025?

Yes, 1 citation was issued (0 Type A, 1 Type B). The first citation was for: "Based on record review, the licensee did not comply with the section cited above in 5 out of staff files which poses a ..."

What type of inspection was this?

This was a inspection inspection. inspection inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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