197607898-11-2-2023-11-AS-WGIS-CX7UG6-20231102153349

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607898
Report Date: 11/02/2023
Date Signed: 11/02/2023 03:34:04 PM

Document Has Been Signed on 11/02/2023 03:34 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	COASTAL HOUSE, INC.		FACILITY NUMBER:	197607898
ADMINISTRATOR:	CLAUDIA PRECIADO		FACILITY TYPE:	740
ADDRESS:	2527 S. BUNDY DRIVE		TELEPHONE:	(310) 770-2029
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90064
CAPACITY:	6	CENSUS: 4	DATE:	11/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:			TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 11/02/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual visit using the full CAREs tool. LPA met with Care Staff, Evelyn Navarro, and the purpose of the visit was explained. The facility is licensed to serve 6 elderly residents aged 60 and above. The facility has a fire clearance for 5 non-ambulatory and one bedridden, and an approved hospice waiver for five (5) residents. Currently there are four (4) residents residing at the facility. Physical Plant/Structure LPA toured the facility with Care Staff, Evelyn Navarro. The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident rooms, two and a half (2.5) bathrooms, living area, dining area, kitchen, a detached office area in the backyard, a detached locked storage area and an outside shaded patio area with an umbrella and ample seating. All walkways and exits around the house were observed clean, clear, and free of obstructions, debris, and hazards. LPA did not observe any bodies of water on the premises. Bedrooms LPA inspected all bedrooms and found they contained the required furnishings. All rooms had a bed, dresser, nightstand, chair, and adequate storage space for resident’s personal belongings. All beds had the required linens including a mattress pad, fitted sheets, blanket, comforter, and pillow. LPA observed an ample supply of linens in good repair stored in cabinets in the hallway. All bedrooms had ample lighting. Bathrooms The bathrooms were found to be within Title 22 regulations and were operational. All showers had nonskid mats, a shower chair, and secured safety handrails. The water temperature measured between 110.5-degress and 113.6-degrees Fahrenheit. LPA observed an ample supply of towels and wash clothes stored in a cabinet in the hallway. LPA observed an ample supply of hygiene supplies and incontinent products secured in a locked storage area in the backyard. Continued on LIC809-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COASTAL HOUSE, INC.	FACILITY NUMBER: 197607898
	VISIT DATE: 11/02/2023

NARRATIVE

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Kitchen The kitchen was inspected. All appliances were observed to be operational and in good repair. LPA observed an ample supply of cookware, dishware, and cutleries. LPA observed a 3-day supply of perishable and 7-day supply of non-perishable food available and properly stored and labeled. All cleaning supplies are secured in a locked cabinet under the kitchen sink. All sharps are secured in a locked drawer in the kitchen. LPA observed emergency food, canned goods, extra refrigerator/freezer, and sanitary supplies secured in a locked storage area in the backyard. The washer and dryer are located in the kitchen.
Common Rooms LPA inspected all common areas. LPA observed the facility to be appropriately furnished at the time of visit. LPA observed reading materials, games, and activities stored in the dining room. LPA observed all hallways and walkways were clean, clear, and free of obstructions and hazards. The facility was maintained at a comfortable temperature.
Medications All Centrally Stored Medications are secured in locked drawer, and cabinet in the kitchen. LPA reviewed the medication and MARs for four residents. All four (4) resident’s MARs and medication are consistent with properly documented records.
Safety All smoke detectors and carbon monoxide detector are operational. LPA observed two (2) fully charged fire extinguisher, one in the kitchen and one in the living room. All exits are clearly marked. LPA observed a facility sketch with all exits, evacuation routes, and shut off valves posted in the facility. The facility has a working landline telephone. All mandated signs were posted throughout the facility.
Infection Control During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed all staff wearing masks. A 60-day supply of PPEs was observed secured in a locked storage area in the backyard. LPA observed all mandated infection control posters were posted.

File Review/Interviews LPA will conduct file reviews at a later date. LPA interviewed two (2) staff and they were able to answer questions regarding policy, procedure, resident care, and resident personal rights.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See LIC809-D

An exit interview was conducted with Care Staff, Evelyn Navarro, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/02/2023 03:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COASTAL HOUSE, INC.	FACILITY NUMBER: 197607898
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(I)(8)

87705 Care of Persons with Dementia (I) The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (8) Fire and earthquake drills conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff. This requirement is not met as evidenced by
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by not conducting an emergency drill in over a year, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/09/2023
	Plan of Correction
1 2 3 4	Administrator will conduct a fire or earthquake drill with direct care staff and send LPA documented proof of drills performed. Administrator will ensure drills are conducted once every three months.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

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