Capistrano Senior Living

Type of visit: Required - 1 Year

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 125 non-ambulatory residents. Facility has an approved hospice waiver for 25 residents and the facility currently has 118 residents. Executive Director (ED) Bryan Hadley arrived to assist with the inspection. LPA along with staff toured the facility at 10:30 AM. LPA toured the physical plant, checked food service, and facility documentation. The facility is a two story building with 114 resident rooms which includes a memory care unit. LPA selected 12 random resident rooms to inspect. 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 102.2 degrees F and 109.5 degrees F in all bathrooms checked. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. At 10:45am, LPA observed prescription nasal spray in Resident 1 (R1)'s bathroom. At 10:50am, LPA observed over the counter pain medication in Resident 3 (R3)'s bathroom. At 11am, LPA observed medications in Resident 4 (R4)'s bathroom. At 11:17am, LPA observed neosporin and antiseptic spray in Resident 2 (R2)'s bathroom. Review of their most recent medical assessments on file for those four residents state they are not allowed to store medications in their rooms. Common areas were clean and clear of hazards. Egress exit alarms were operational during today's visit. The facility's four stairwells had an evacuation chair each. LPA toured the kitchen and observed sufficient perishable and non-perishable food supply. Kitchen appliances were operational during today's visit. Fire alarm systems were last serviced on 6/9/2026. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts monthly emergency drills with the last drill conducted on 6/8/2026. Outside grounds were toured. Courtyards were clear of hazards. There is shaded outdoor seating for residents. Exit gates are unlocked and operational. LPA observed the emergency food and water supply. First aid kit contained all required items including tweezers, scissors and thermometer. LPA observed residents partaking in exercises in the therapy room and watching World Cup soccer in the main lounge area. LPA reviewed 12 resident files and five staff files. Resident files contained required documentation including admission agreements and physician reports. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. Medications are stored in carts in the medication room. Medications are being administered per physician order. LPA observed a resident room with a camera. LPA interview with resident stated they had provided consent to allow family to observe. Based on the observations made during today’s visit, a deficiency is 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 along with appeal rights.the state’s words, verbatim · CDSS document, Jun 11, 2026

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Collateral

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a collateral visit to further the investigation into complaint # 22-AS-20260127083506 which was filed at another facility. LPA met with Business office manger Melissa Flores and explained the reason for the visit. LPA met with Resident 1 (R1) and explained the reason for the visit. LPA interviewed R1, thanked them for their time and ended the interview. An exit interview was conducted with Business office manger Melissa Flores and a copy of the report provided.the state’s words, verbatim · CDSS document, Jan 29, 2026

Allegation investigated: Facility mismanaged resident's medication Facility did not ensure that resident received medical care

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with the Wellness Director Anabella Real and explained the reason for the visit. The investigation into the allegation, facility mismanaged resident's medication, revealed the following. It was reported that Resident 1(R1) did not receive Eliquis and Lasix for three days. A review of records show R1 moved into the facility on October 25, 2024 for respite care. R1's medication was handled by the facility. Staff reported that R1 provided medication from their last hospital visit at the time of move in. The Wellness Director reported that when R1 moved in, R1 did not have a doctor so they recommended a doctor for R1. R1 did not choose a doctor until October 31, 2024. R1 was self responsible and their physician report dated October 18, 2024 shows R1 can leave the facility unassisted. Staff reported that R1 provided medication at the time of move in on October 25, 2024 including Eliquis and Lasix. Staff reported that R1 did run out of Eliquis and Lasix but it could not be refilled until R1 choose a doctor. The Wellness Director reported that R1 choose a doctor on October 31, 2024. Unsubstantiated R1 and their emergency contact never responded to requests for an interview. The Wellness Director reported that R1 did not agree to having a doctor until after their medication ran out. Facility staff reported that R1 had no reported issues from October 25, 2024 to November 4, 2024. Staff reported that until R1 picked a physician there was nothing they could do about having R1's prescriptions filled. Facility records show R1 had a doctor visit on October 31 and their doctor prescribed medications that day. The Wellness Director reported that R1 was advised to choose a doctor as soon as possible so any required care wouldn't be delayed. Staff reported that once prescribed all medications were issued as prescribed. A review of medication records show R1 was prescribed 23 medications after their appointment. None of the evidence gathered supports the allegation, therefore the allegation, facility mismanaged resident's medication, is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. The investigation into the allegation, facility did not ensure that resident received medical care, revealed the following. It was reported that when R1 moved in they were told they would have home health visits and no home health visits were provided until a week after R1 moved into the facility. The Wellness Director reported that at the time of move in R1 had no doctor and once they had a doctor (R1 choose a doctor on October 31, 2024) a home health visit was scheduled for November 3, 2024. Facility records show R1 had a home health visit on November 3, 2024. The Wellness Director reported that R1 was advised to choose a doctor as soon as possible so any required care wouldn't be delayed. It was reported that on November 5, 2024, R1 repeatedly called for assistance and staff did not answer for 90 minutes. R1 and their emergency contact never responded to requests for an interview. Staff 1 reported that around 4:00 am, R1 requested assistance using the call system. Staff 1 reported they responded and saw R1 was having issues breathing. Staff 1 reported that they were going to call 911 but R1 reported they had already called 911. The facility call system only keeps records for one week and the records were no longer available at the time of the initial 10-day visit to begin the investigation. R1 was transported to the hospital. The Administrator reported that after R1 went to the hospital on November 5, 2024 they never returned to the facility. The Administrator reported that R1 did not return any calls to the facility. Based on the evidence gathered the allegation, facility did not ensure that resident received medical care, is deemed unsubstantiated, although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Dec 11, 2025 · control 22-AS-20241106125531

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Jun 18, 2025

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA met with Memory Care Director Dannea Maurer and explained the reason for the visit. The Agency received an incident report on December 09, 2024 concerning the health and safety of Resident 1. LPA and Toured the facility. No obstacles or hazards observed. LPA met with Resident 1. No health or safety concerns noted. LPA interviewed staff. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.the state’s words, verbatim · CDSS document, Dec 9, 2024

Type of visit: Required - 1 Year

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, 2025. Facility is approved for delayed egress exits in the memory care unit. Facility is a two story building with 114 resident rooms which includes a memory care unit. LPA and the Executive Director (ED) toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the hallway next to 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. LPA observed that the refrigerators and the freezers had temperature logs posted on them. The refrigerators and freezers were at the required temperatures. 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 106.7 degrees Fahrenheit to 111.5 degrees Fahrenheit. There is a library next to the dining room with games and puzzles and a TV room for residents. There are fire extinguishers on each floor and all fire extinguishers are fully charged. The facility has 4 stairwells. LPA observed an emergency evacuation chair at the top of each stairwell. The last emergency disaster drill was conducted on June 12, 2024. 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 in memory care with shaded seating for residents to sit outside. The delayed egress exits in memory care tested operational. The fire alarm/fire detection system was inspected and tested operational on June 6, 2024. LPA observed medications are kept secured in a medication cart that is locked in the medication room. LPA interviewed staff and residents. LPA reviewed 5 staff files with no discrepancies observed. All staff files reviewed had the required annual training. LPA reviewed 10 resident files, no discrepancies observed. LPA inspected resident medications. LPA observed that Resident 1 was missing 2 of their 12 prescribed medications. No other discrepancies observed. No obstacles or hazards were noted inside or outside of the facility. Deficiencies are being cited per title 22 Division 6 of the California Code of Regulations on the attached LIC 809D. An exit interview was conducted with the Executive Director and a copy of the report provided along with appeal rightsthe state’s words, verbatim · CDSS document, Jun 22, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.