198320391-8-7-2023-11-AS-MLEN-CTTS3N-20230717133125

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320391
Report Date: 07/17/2023
Date Signed: 08/07/2023 09:44:42 AM

Document Has Been Signed on 08/07/2023 09:44 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/07/2023 09:39 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

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 Monday, July 17, 2023, at 8:30AM, Licensing Program Analyst (LPA) Mario Leon initiated an announced Pre-Licensing Visit to the above mentioned facility. An application was submitted to the Department of Social Service, Community Care Licensing Division (CCLD) dated 05/02/2023 for an initial application for a Residential Care Facility for the Elderly (RCFE) aged 60+. The requested capacity is six (6) non-ambulatory. The Fire Safety Inspection Request is granted and approved for 5 non-ambulatory and 1 ambulatory resident. LPA Leon verified both an approved Mitigation Plan Report and Infection Control Plan. Structure: The facility is a single-story-family home located in a residential neighborhood. The facility has a living room, kitchen, dining area, 5 bedrooms, 3 bathrooms, 2 offices, shaded patio area, indoor/outdoor activity areas and an attached garage. The front and back yard landscape is in good condition at the time of the visit. Bedrooms: Bedrooms 1-5 are designated as client bedrooms and office 1 will be designated as staff sleeping room. Bedroom 4 is designated as a shared room. The bedrooms have a twin-sized bed, chair, night stand with storage, lamps, and closet space available. Bathrooms: Bathrooms 1-2 have a working toilet, grab frame surrounding toilet, washbasin, and shower with grab bars, anti-slip tape strips in the shower, and covered trash cans. Bathroom 3 is designated as staff restroom. See continued LIC809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COAST TO COAST SENIOR WELLNESS	FACILITY NUMBER: 198320391
	VISIT DATE: 07/17/2023

NARRATIVE

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Linens & Hygiene Supplies: The required linen supplies include, pillowcases, mattress padding, fitted sheet, blanket, bedspreads and mattress protectors. An adequate supply of linens is kept in the hallway cabinet. Hygiene supplies will be stored in the hallway closet bins. Emergency Phone Numbers: Emergency phone numbers are posted on the wall on the cork board in the dining area. The facility will have a landline as of Wednesday 07/19/23, through Spectrum. Exit Plan & Facility Sketch: The exit plan and facility sketch are posted on the cork board in the dining area . There is one (1) fully charged fire extinguisher located in the kitchen area, outside of the staff restroom. Food Service: Dishes, cups, pots, pans, and flatware are stored in the kitchen cupboards, were inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils will be stored in a locked kitchen cabinet, trash can drawer is located in the kitchen. Smoke/Carbon Monoxide Detectors: There are hardwired smoke alarms and carbon monoxide detectors located throughout the facility in the hallways and bedrooms that are operational. Appliances: Refrigerator, stove/oven, microwave, and washer/dryer are installed and all are in working condition. There is central air and heating throughout the home. The hot water heater is located within the attached garage. Toxins: Cleaning supplies and toxins will be stored in the locked chemical supply hallways closet and only accessible to staff. Water Temperature: The hot water was tested in the bathrooms and kitchen the temperature was tested at 120 degrees Fahrenheit within the normal limits (105-120F degrees). Medication, First-Aid Kit & Manual: Centrally stored medications will be kept in a locked cabinet adjacent to the kitchen/dining area, first-aid kit and manual will be locked in the hallway closet. There are sufficient bandages, tweezers, thermometer, scissors, etc. Staff & Resident Files: The staff and resident records will be kept confidential and will be stored in a locked file cabinet in office 2, nearest the front door. The applicant will maintain a surety bond and all resident cash resources will be handled by family. All residents will be privately funded, applicant will not co-mingle funds. Pools/Jacuzzi & Pets: No bodies of water and no pets were found on these premises. Fire Clearance: Fire clearance was approved on 05/25/2023. The facility yard is free of debris and hazard.
See continued LIC809-C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: COAST TO COAST SENIOR WELLNESS	FACILITY NUMBER: 198320391
	VISIT DATE: 07/17/2023

NARRATIVE

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Component III Orientation: Component III was completed with the Applicant during the Pre-Licensing visit. Information was provided about how to operate the facility within substantial compliance. When the applicant was asked if she understood Title 22 Regulations he responded in the affirmative.

Accordingly, LPA Leon will submit a copy of this facility evaluation report to the Central Applications Branch (CAB) for review. If the applicant has questions regarding the status of the application, she has been instructed to communicate with the CAB Analyst assigned to their application.

LPA Leon provided a copy of the Facility Evaluation Report LIC809 and LIC809-Cs to the Applicant, Leslie Bauguess.

An exit interview was conducted.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Mario Leon	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023

LIC809 (FAS) - (06/04)

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