Inspection Reports for Capistrano Senior Living

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.

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.

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.

No health or safety concerns were noted during the visit. No deficiencies were cited as a result of this inspection.

The Licensing Program Analyst conducted an unannounced required annual inspection of the Capistrano Senior Living Facility to assess compliance with regulatory standards.

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.

An unannounced visit was conducted to investigate a complaint alleging that the facility was mismanaging a resident's medication.

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.

The complaint alleging mismanagement of resident's medication was substantiated based on evidence including interviews, medication administration records, and facility documentation.

An unannounced complaint investigation visit was conducted in response to an allegation that unqualified staff administered injections to residents in care.

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.

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.

An unannounced case management visit was conducted to review health checks and provide consultation regarding reporting requirements and the Guardian System.

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.

Licensing Program Analyst Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation) of the facility.

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.

An unannounced complaint investigation visit was conducted in response to an allegation that staff did not assist a resident with their shower.

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.

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.

An unannounced post licensing visit (mitigation) was conducted to evaluate the facility's compliance with licensing requirements.

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.

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.

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.

The visit was conducted as part of a Change of Ownership application process for the facility.

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.

Licensing Program Analyst Joseph Alejandre conducted an announced pre-licensing inspection visit to evaluate the facility for licensure as a continuing care retirement community.

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.

The visit was conducted as part of a Change of Ownership application process for the facility.

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.