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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320114
Report Date: 07/29/2021
Date Signed: 07/29/2021 04:16:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SUNCOAST SENIOR LIVING AT LONG BEACHFACILITY NUMBER:
198320114
ADMINISTRATOR:KIM, KI HWANFACILITY TYPE:
740
ADDRESS:2520 GONDAR AVETELEPHONE:
(718) 683-1000
CITY:LONG BEACHSTATE: CAZIP CODE:
90815
CAPACITY:6CENSUS: 3DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Tony / Stephanie KimTIME COMPLETED:
04:00 PM
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On 07/29/21/ Licensing Program Analyst (LPA) Jade Jordan conducted an unannounced annual inspection
with an emphasis on inspection control. LPA was met by Facility Administrator Ki Hwan "Tony" Kim; and Stephanie Mangapit. The Purpose of the visit was explained.

The Facility is Licensed to serve Individuals over ages 60 years and above. The capacity is for six (6) ambulatory clients, of which six (6) can also be non- ambulatory clients, and is approved for 6 hospice clients.
Facility is a one story family home with six (6) bedrooms, one (1) staff break room, (6) full bathrooms, family room, living room, dining area, nook office area, kitchen, and garage. The one (1) car locked attached garage is located in the front of the property, and inaccessible to residents. The front yard, backyard and patios are in good condition. Walkways are free of hazards and debris. All Residents rooms have the required furniture. Beds have the required linen/supplies which include, pillowcase, fitted sheet, blanket and bedspreads, all rooms have required mattress pads. Ample supply of linen is stored in resident rooms. Cleaning supplies, and toxins are in the locked garage, only accessible to staff. The Hot water was tested and measured at 111.0 degree's which is within title 22 regulations. The facility last conducted a fire drill and had the fire department check hardwired smoke alarms in March of 2021. Both Administrators have valid Administrator certificates that expire on 12/04/21. The kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly and fire extinguisher was fully charged. Resident and staff files were reviewed, and had required documentation's.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SUNCOAST SENIOR LIVING AT LONG BEACH
FACILITY NUMBER: 198320114
VISIT DATE: 07/29/2021
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LPA observed staff wearing masks, Visitor Log /Symptom screening Log, Designated isolation room, required Covid-19,Postings, 30 day supply of some PPE's and other required documents, including phone numbers are posting as mandated by the DPH and CCLD



Technical advisory was given for the following areas:

* 30 day supply of face shields
* 30 Day supply of gowns
* N95 Fit Testing Pins 21-12-ASC; 21-10-ASC; 21-09-ASC


An exit interview was conducted a copy of this report was given.
No citations were issued during this visit.
SUPERVISOR'S NAME: Michael CavaTELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jade JordanTELEPHONE: (650) 388-2300
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
LIC809 (FAS) - (06/04)
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