197607898-11-9-2024-11-AS-AINZ-DAUQS7-20241109112505

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607898
Report Date: 11/09/2024
Date Signed: 11/09/2024 11:25:20 AM

Document Has Been Signed on 11/09/2024 11:25 AM - 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	COASTAL HOUSE, INC.		FACILITY NUMBER:	197607898
ADMINISTRATOR/ DIRECTOR:	CLAUDIA PRECIADO		FACILITY TYPE:	740
ADDRESS:	2527 S. BUNDY DRIVE		TELEPHONE:	(310) 770-2029
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90064
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	11/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:39 AM
MET WITH:	Rosaura Ortiz/Facility Staff		TIME VISIT/ INSPECTION COMPLETED:	11:30 AM

NARRATIVE

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On 11/9/2024, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Rosaura Ortiz /Facility Staff. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) elderly adults ages 60 and above, of which (5) can be non-ambulatory and (1) Bedridden. The facility has an approved hospice waiver for (5).

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.

LPA Iniguez and the facility staff toured the physical plant. There were no bodies of water or obstructions on the premises. LPA inspected a total of (4) bedrooms and (2) bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 116.5°F to 118.2°F, and the room temperature ranged from 76°F to 78°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.

Eva M Alvarez	TELEPHONE: (323) 629-7047
Alfonso Iniguez	TELEPHONE: 323-981-1755
	DATE: 11/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024

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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: COASTAL HOUSE, INC.	FACILITY NUMBER: 197607898
	VISIT DATE: 11/09/2024

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During the visit, LPA Iniguez observed that the facility was clean, sanitary, and appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there was sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted in October/2024.

Residents and Staff records locked at the time of the inspection. LPA reviewed (3) Medication Administration Records (MARs) and found no discrepancies.

LPA observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility. A copy of liability insurance will be brought at the office. Facility Annual Fess current. Facility Annual Fees are not current.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See details below:

-See D pages for details.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Rosaura Ortiz / Facility Staff.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/09/2024 11:25 AM - 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: COASTAL HOUSE, INC.	FACILITY NUMBER: 197607898
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in not having a desiganted person when the administrator can not be present at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2024
	Plan of Correction
1 2 3 4	Licensee will ensure a desidnated person is available when administrator is not at all times. As plan of correction, licensee will chose a designee and train them to comply with tittle 22 regulations. Licensee will show the designated staff during the case managment visit on 11/19/24 to LPA Iniguez.

Section Cited

Personnel Records

(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in having staff records locked which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2024
	Plan of Correction
1 2 3 4	Licensee will ensure personnel records are available to the licensing agent at all times. As plan of correction licensee will bring staff records to office meeting on 11/19/24 for LPA Iniguez to review.

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

Eva M Alvarez	TELEPHONE: (323) 629-7047
Alfonso Iniguez	TELEPHONE: 323-981-1755
	DATE: 11/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/09/2024 11:25 AM - 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: COASTAL HOUSE, INC.	FACILITY NUMBER: 197607898
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in having residents records locked which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2024
	Plan of Correction
1 2 3 4	Licensee will ensure residents records are readily available for licensing agent at all times. As plan of correction, licensee will bring resident records to office meeting on 11/19/24 for LPA Inigues to review.

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.

Eva M Alvarez	TELEPHONE: (323) 629-7047
Alfonso Iniguez	TELEPHONE: 323-981-1755
	DATE: 11/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 11/09/2024 11:25 AM - 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: COASTAL HOUSE, INC.	FACILITY NUMBER: 197607898
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

87755 Inspection Authority of the Licensing Agency (a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or without advance notice. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation), the licensee did not comply with the section cited above in facility staff and administrator were not aware of licensing agents coming to inspect the facility even on the weekends which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2024
	Plan of Correction
1 2 3 4	Licensee will ensure all facility staff are aware of licensing agents can isnpect the facility without advance notice and regular businees hours incluiding weekends. As plan of correction licensee will train all facility staff about this regulation and present the training to LPA Iniguez during office meeting on 11/19/24.

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.

Eva M Alvarez	TELEPHONE: (323) 629-7047
Alfonso Iniguez	TELEPHONE: 323-981-1755
	DATE: 11/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2024

LIC809 (FAS) - (06/04)

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