<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320059
Report Date: 02/01/2024
Date Signed: 02/02/2024 08:13:53 AM


Document Has Been Signed on 02/02/2024 08:13 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:OCEAN BREEZE CARE HOME IIFACILITY NUMBER:
198320059
ADMINISTRATOR:MACELLVEN, GREGFACILITY TYPE:
740
ADDRESS:26509 ROLLING VISTA DRTELEPHONE:
(310) 721-9667
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 5DATE:
02/01/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:ADMINISTRATOR GREG MACELLVENTIME COMPLETED:
12:00 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 02/01/2024 at 09:30 AM, Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced annual inspection visit at the Ocean Breeze Care Home 2 Facility. LPA Calderon was allowed entry into the facility by Administrator Greg Macellven. Administrator Greg Macellven was asked questions regarding the full care tools control package (13) sections. Administrator Greg Macellven took LPA Calderon temperature prior to entrance into the facility. Facility is licensed for (6) non-ambulatory residents. The facility has an approved hospice waiver for (2) residents. LPA Calderon explained to Administrator Greg Macellven, the purpose of the one-year (1) Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: six (6) resident service records, six (6) resident medication records, two (2) staff records. LPA Calderon interviewed six (6) residents and two (2) staff members for visit. LPA Calderon inspected the inside facility and outside grounds to include all common areas. The facilities’ last fire drill was conducted on 11/03/2023. The one-story residential home consists of six (6) resident bedrooms, three (3) resident bathrooms, living room, dining room, family room, kitchen, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day (2) supply perishable and seven-day (7) supply of non-perishable foods are present in the facility. Emergency Water seven-day (7) supply is found in the garage.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: OCEAN BREEZE CARE HOME II
FACILITY NUMBER: 198320059
VISIT DATE: 02/01/2024
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
26
27
28
29
30
31
32
LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of resident’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 111 degrees Fahrenheit. Bathroom #2 hot water temperature properly measured at 110 degrees Fahrenheit. Bathroom #3 hot water temperature properly measured at 110 degrees Fahrenheit. Kitchen hot water temperature properly measured at 115 degrees Fahrenheit. Facility (2) carbon Monoxide and (8) Smoke Detectors hard wired and were tested and are working properly. The facility two (2) Fire Extinguishers were checked and found to be fully charged and accessible. All exit doors in the facility have alarm systems. All toxins and knifes are locked/secured and inaccessible to residents. Medications are centrally stored and in a locked storage cabinet. Facility first aid kit (1) is fully stocked with manual was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to residents. LPA Calderon noted the Administrator Greg Macellven Certification # 6040801740 expiration date of 06/08/2024 was valid at time of visit. The facility does NOT handle resident's money/cash resources and a NO Surety bond is needed. Commercial General Liability Policy #HFS0007978 policy period from 02/17/2023 to 02/17/2024 underwritten by Scottsdale Indemnity Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. LPA Calderon spoke to Administrator Greg Macellven who will email full copy of insurance contact which shows all coverages to LPA Calderon no later than 02/28/2023. All the required documents are posted in the facility in a clearly visible area to all staff, clients, and guests. LPA Calderon reviewed LIC500 and noted all staff associated to facility per LIS. LPA Calderon reviewed the resident roster, LPA Calderon confirmed residents’ interview are on resident roster.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: OCEAN BREEZE CARE HOME II
FACILITY NUMBER: 198320059
VISIT DATE: 02/01/2024
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
26
27
28
29
30
31
32
During the visit, LPA Calderon observed the facility infection control practices. LPA Calderon observed screening protocols for visitors, staff, and residents, sanitizing stations (Located in common areas and restrooms). LPA Calderon observed staff and residents were wearing face coverings, an isolation room and required postings throughout the facility. LPA Calderon observed the facility has a thirty-day (30) supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Administrator Greg Macellven to continuously monitor the Centers for Disease Control (CDC) website and Community Care Likening Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did not observe any deficiencies therefore NO citations were issued at this time. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Greg Macellven.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Jose CalderonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3