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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320114
Report Date: 10/17/2023
Date Signed: 11/03/2023 09:34:38 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/10/2023 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20231010121617
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: 5DATE:
10/17/2023
UNANNOUNCEDTIME BEGAN:
08:57 AM
MET WITH:Sofia Ociones, Assistant AdministratorTIME COMPLETED:
11:58 AM
ALLEGATION(S):
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Staff are not meeting a fire safety requirement
INVESTIGATION FINDINGS:
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On 11/03/23 Licensing Program Analyst (LPA) Mario Leon delivered an amended report. This is an amendment of a report provided on 10/17/23. The purpose of this amendment is to provide additional information regarding the investigation conducted for this complaint.
Licensing Program Analyst (LPA) Mario Leon conducted an unannounced complaint visit to above facility. LPA arrived at facility and was met by Sofia Ociones, Assistant Administrator, and explained the purpose of the visit is to investigate on the allegation listed above and was allowed entry to the facility.

The investigation consisted of the following:
On 10/16/2023 LPA conducted record reviews of California Code of Regulation, Title 19 - Public Safety Division 1 - State Fire Marshal Chapter 3 - Fire Extinguishers Article 6 - Inspection, Maintenance and Required Service Intervals - § 575.1 - Maintenance and Required Service Intervals, which indicates that fire extinguishers shall be subjected to maintenance annually as described in this chapter. On 10/17/2023 LPA toured the inside and outside grounds of the facility and requested copies of facility documents. LPA conducted interviews with four (4) facility staff (S1-S4).
Report continues, see LIC9099C
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20231010121617
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SUNCOAST SENIOR LIVING AT LONG BEACH
FACILITY NUMBER: 198320114
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2023
Section Cited
CCR
87203
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Fire Safety. All facilities shall be maintained in conformity with the regulation adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This regulation is not met as evidenced by:
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LPA and Assistant Administrator have agreed that Assistant Administrator will purchase two (2) new fire extinguishers, provide LPA receipt of purchase and will keep yearly records of services on file moving forward. LPA email address: Mario.Leon@dss.ca.gov
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Based on record reviews, observation and interviews the licensee failed to ensure that fire extinguishers are subjected to annual maintenance per Title 19, Divison 1 -State Fire Marshal, Chapter 3 - Fire Extinguisher which poses a potential health and safety risk to persons in care.
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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: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20231010121617
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SUNCOAST SENIOR LIVING AT LONG BEACH
FACILITY NUMBER: 198320114
VISIT DATE: 10/17/2023
NARRATIVE
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The investigation revealed the following:
Allegation: Staff are not meeting a fire safety requirement. It has been alleged that the fire extinguisher(s) present at the facility do not have service records, purchase records, or do not have tags blocked in showing proper yearly inspection by licensed State Fire Marshall officials.

During today's tour of the facility, LPA and Assistant Administrator, Sofia Ociones, inspected two fire extinguishers by the bedroom hallway. LPA and Assistant Administrator did not observe both fire extinguishers showing any service records, purchase records or tags showing yearly fire inspection by a State Fire Marshall official. LPA requested the quarterly fire drill, proof of purchase of fire extinguisher or service records from Assistant Administrator. Assistant Administrator was not able to provide records as requested.

Based on LPA’s observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division six (6) is being cited on the attached LIC 9099D.

An exit interview was held with Assistant Administrator, Sofia Ociones, and a copy of this report and appeal rights have been provided.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3