Inspection Report Summary
Most inspections of Capistrano Senior Living Facility were clean, with the most recent report on June 18, 2025, citing only a minor deficiency related to incomplete staff training hours. Earlier reports included some substantiated complaints involving medication mismanagement and unqualified staff administering injections, both posing immediate health risks, but these issues have not recurred in recent inspections. The facility also had a past incident in 2021 where a resident eloped due to inadequate supervision. Several complaint investigations were unsubstantiated, and no fines or enforcement actions were listed in the available reports. Overall, the facility appears to have improved over time, with recent visits showing compliance and only isolated minor issues.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 103
Capacity: 125
Deficiencies: 1
Jun 18, 2025
Visit Reason
The inspection was an unannounced required annual inspection conducted by Licensing Program Analyst Joseph Alejandre to assess compliance with licensing requirements at Capistrano Senior Living Facility.
Findings
The facility was generally found to be in compliance with licensing requirements, including clean and operational resident rooms, proper food storage, and emergency preparedness. However, a deficiency was cited for failure to provide 4 hours of required annual training specific to postural supports, restricted health conditions, and hospice care for 5 staff members.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not comply with training requirements for 5 staff files, missing 4 hours of training specific to postural supports, restricted health conditions, and hospice care. | Type B |
Report Facts
Staff files reviewed: 5
Resident files reviewed: 10
Emergency drill date: Apr 25, 2025
Plan of Correction Due Date: Jul 3, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bryan Hadley | Executive Director | Met with Licensing Program Analyst during inspection and named in report |
| Joseph Alejandre | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Census: 111
Capacity: 125
Deficiencies: 0
Dec 9, 2024
Visit Reason
Licensing Program Analyst Joseph Alejandre made an unannounced case management visit following receipt of an incident report concerning the health and safety of a resident.
Findings
No health or safety concerns were noted during the visit. No deficiencies were cited as a result of this inspection.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced case management visit. |
| Dannea Maurer | Memory Care Director | Met with the Licensing Program Analyst during the visit. |
Inspection Report
Annual Inspection
Census: 106
Capacity: 125
Deficiencies: 1
Jun 22, 2024
Visit Reason
The Licensing Program Analyst conducted an unannounced required annual inspection of the Capistrano Senior Living Facility to assess compliance with regulatory standards.
Findings
The facility was generally found to be clean, organized, and compliant with most regulations, including proper food storage, fire safety equipment, and resident room conditions. However, a deficiency was cited due to Resident 1 missing 2 of their 12 prescribed medications, posing an immediate health and safety risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Resident 1 was missing 2 out of their 12 prescribed medications (MiraLax Packet 17 GM and Oxycodone HCI tablet 5 MG), indicating noncompliance with medication administration regulations. | Type A |
Report Facts
Deficiencies cited: 1
Resident medications missing: 2
Resident medications prescribed: 12
Plan of Correction due date: Jun 24, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Sheila Santos | Licensing Program Manager | Supervisor overseeing the inspection |
| Bryan Hadley | Executive Director | Facility administrator met during inspection and involved in exit interview |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 125
Deficiencies: 1
May 10, 2023
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that the facility was mismanaging a resident's medication.
Findings
The investigation found that Resident 1 did not receive several prescribed medications from 4/22/23 to 4/26/23 and on 4/30/23, posing an immediate risk to health and safety. Conflicting reports were noted regarding medication administration, but the preponderance of evidence substantiated the allegation of medication mismanagement.
Complaint Details
The complaint alleging mismanagement of resident's medication was substantiated based on evidence including interviews, medication administration records, and facility documentation.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Incidental Medical and Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: based on a review of records R1 was not administered any medications from 4/22/23 to 4/26/23 and on 4/30/23. This poses an immediate risk to the health & safety of residents in care. | Type A |
Report Facts
Census: 97
Total Capacity: 125
Deficiency Due Date: May 11, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bryan Hadley | Executive Director | Met with during investigation and named in report |
| Nina Dadabhoy | Health and Wellness Director | Met with during investigation and named in report |
| Luz Adams | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 125
Deficiencies: 1
Oct 28, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that unqualified staff administered injections to residents in care.
Findings
The investigation substantiated that non-licensed staff performed glucose testing and administered insulin injections to residents without their aid, which violates California regulations and poses an immediate health and safety risk.
Complaint Details
The complaint alleging unqualified staff administering injections was substantiated based on interviews, record reviews, and staff reports. Memory care residents could not verify the information. The preponderance of evidence standard was met.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee failed to ensure that only appropriately skilled professionals administer medication including injections to diabetic residents, as non-licensed staff administered insulin injections and performed glucose testing without assistance. | Type A |
Report Facts
Capacity: 125
Census: 93
Deficiency count: 1
Plan of Correction Due Date: Oct 29, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Bryan Hadley | Administrator | Facility administrator met during the investigation and named in the report |
| Luz Adams | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Census: 92
Capacity: 125
Deficiencies: 0
Jul 21, 2022
Visit Reason
An unannounced case management visit was conducted to review health checks and provide consultation regarding reporting requirements and the Guardian System.
Findings
No citations were issued during this visit. The facility had suspended community and group activities, used disposable utensils for meal preparation, and had infection control measures in place in the memory care unit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bryan Hadley | Executive Director | Met with Licensing Program Analysts during the visit and received consultation. |
| Albert Marin | Licensing Program Analyst | Conducted the unannounced case management visit and provided consultation. |
| Celine De Perio | Licensing Program Analyst | Conducted the unannounced case management visit and provided consultation. |
Inspection Report
Annual Inspection
Census: 92
Capacity: 125
Deficiencies: 0
Jun 7, 2022
Visit Reason
Licensing Program Analyst Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation) of the facility.
Findings
The facility was found to be clean, organized, and compliant with no deficiencies observed. Staff were wearing masks, hand sanitizing stations were present, medications were secured, fire extinguishers were charged, and emergency equipment was in place. The facility has an approved Covid-19 mitigation plan.
Report Facts
Perishable food supply: 2
Non-perishable food supply: 7
PPE supply: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Hadley | Executive Director | Met with Licensing Program Analyst during inspection and consulted regarding Covid-19 mitigation and reporting requirements |
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced annual inspection visit |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 125
Deficiencies: 0
May 19, 2022
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not assist a resident with their shower.
Findings
The investigation found that the resident had a preferred caregiver who switched shifts, resulting in the resident refusing showers at the preferred time. The facility attempted to accommodate the resident's preferences and documented refusals. The allegation was deemed unfounded as the resident was refusing showers and the facility provided varied meal options.
Complaint Details
The complaint alleged that staff did not assist a resident with their shower. The investigation was unannounced and included interviews, facility tour, and document review. The allegation was found to be unfounded.
Report Facts
Capacity: 125
Census: 87
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Brian Hadley | Facility representative who met with the Licensing Program Analyst during the visit | |
| Alisa Ortiz | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Original Licensing
Census: 86
Capacity: 125
Deficiencies: 0
Mar 23, 2022
Visit Reason
An unannounced post licensing visit (mitigation) was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The Licensing Program Analyst observed that the facility was clean, organized, and well-maintained with no deficiencies noted. All safety systems, including fire extinguishers, delayed egress exits, and fire sprinkler systems, were operational and no hazards were observed.
Report Facts
Fire drill date: Mar 14, 2022
Fire sprinkler system test date: Feb 24, 2022
PPE supply duration: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ninad Dadabhoy | Health & Wellness Director | Met with Licensing Program Analyst during the visit and toured the facility |
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced post licensing visit |
Inspection Report
Census: 66
Capacity: 125
Deficiencies: 1
Sep 21, 2021
Visit Reason
An unannounced case management visit was made to follow up on an incident report submitted regarding a resident who eloped from the facility on 09/15/2021.
Findings
The facility failed to ensure adequate care and supervision as evidenced by a resident eloping due to staff not responding to a door alarm, posing an immediate health and safety risk to residents.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure care and supervision was provided to Resident 1 who eloped from the facility because staff did not respond to the door alarm. | Type A |
Report Facts
Deficiency due date: Sep 22, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Alejandre | Licensing Program Analyst | Conducted the unannounced case management visit and cited the deficiency |
| Luz Adams | Licensing Program Manager | Named as supervisor and licensing program manager in the report |
| Cynthia Garcia | Administrator | Facility administrator named in the report |
| Ninad Dadabhoy | Met with during the visit |
Inspection Report
Census: 62
Capacity: 125
Deficiencies: 0
Jun 1, 2021
Visit Reason
The visit was conducted as part of a Change of Ownership application process for the facility.
Findings
The applicant and administrator participated in a COMP II telephone interview to verify identification and confirm understanding of California Code Title 22 regulations, covering facility operation, admission policies, staffing, health conditions, emergency preparedness, complaints, and pre-licensing readiness.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Bradshaw | Participant in COMP II telephone interview | |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager |
| Bethany Hunter | Licensing Program Analyst | Named as Licensing Program Analyst |
| Cynthia Garcia | Administrator | Facility Administrator |
Inspection Report
Original Licensing
Census: 64
Capacity: 125
Deficiencies: 0
Jun 1, 2021
Visit Reason
Licensing Program Analyst Joseph Alejandre conducted an announced pre-licensing inspection visit to evaluate the facility for licensure as a continuing care retirement community.
Findings
The facility was toured and inspected including resident rooms, kitchen, dining rooms, laundry, medication room, and common areas. No hazards or obstacles were observed, safety systems were operational, and fire clearance was approved. The facility meets Title 22 Division 6 regulations and is ready for licensure.
Report Facts
Hot water temperature: 105
Facility capacity: 125
Census: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Garcia | Administrator | Administrator present during inspection and named in report |
| Joseph Alejandre | Licensing Program Analyst | Conducted the pre-licensing inspection visit |
Inspection Report
Census: 62
Capacity: 125
Deficiencies: 0
May 27, 2021
Visit Reason
The visit was conducted as part of a Change of Ownership application process for the facility.
Findings
The applicant/administrator participated in a COMP II telephone interview to verify identification and confirm understanding of California Code Title 22 regulations, including facility operation, admission policies, staffing, emergency preparedness, and other regulatory areas.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Garcia | Executive Director | Applicant/administrator participating in COMP II interview |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager |
| Bethany Hunter | Licensing Program Analyst | Named as Licensing Program Analyst |
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