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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001500
Report Date: 10/11/2021
Date Signed: 05/18/2022 08:08:19 AM


Document Has Been Signed on 05/18/2022 08:08 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:BEACH HOMESFACILITY NUMBER:
306001500
ADMINISTRATOR:BEACH, TRISHFACILITY TYPE:
740
ADDRESS:2575 COLUMBIA DRIVETELEPHONE:
(714) 549-9380
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 6DATE:
10/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Care staff Columba MclaurinTIME COMPLETED:
12:03 PM
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Licensing Program Analyst (LPA) Shobhana Frank made an unannounced visit to the facility today to conduct
required 1 year inspection. During today’s visit, LPA met with Care staff Columba Mclaurin and explain the
purpose of today's visit. LPA Frank toured the facility, inspected resident rooms and bathrooms, reviewed
resident and staff records. LPA Frank reviewed centrally stored medications and records, reviewed food
services, and inspected the kitchen.
In addition, LPA Frank tested the hot water temperature, which measured 118.1 degrees F in resident
bathroom. Resident areas were noted to be a comfortable temperature.
Smoke detectors and carbon monoxide detectors were tested and found to be operational. The facility also
has fire extinguisher that was mounted and charged. LPA Frank confirmed food supply: 2 day supply of
perishables and 7 day supply of non-perishable food is available for the number of residents present.
Hygiene supplies and supply of linen were observed in quantities for the number of residents in care. LPA
observed locked areas for toxins and hazardous items. Medication were observed locked in cabinet.
LPA observed COVID - visitation station equipped with hand sanitizer, thermometer, Gloves, visitors log,
COVID posters throughout the facility.
LPA observe the facility to be clean and in good repair. Physical Plant and Safety of Environment/Operational
Requirements.
LPA Frank reviewed : 1.) Designation of Administrative Responsibility (LIC308) 2.) Personnel Report
(LIC500); 3.) Emergency Disaster Plan (LIC610E); 4.) LIC 9020A Client Roster; LIC 808) Mitigation Plan;
Current Liability Insurance.
Based on the observations made during today’s visit, no deficiencies are being cited in area inspected.
This report was discussed with the facility representative and a copy was provided.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2021
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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