306001500-10-12-2022-22-AS-JCHO-CK5UDP-20221012152953

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001500
Report Date: 10/12/2022
Date Signed: 10/12/2022 03:30:08 PM

Document Has Been Signed on 10/12/2022 03:30 PM - 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 HOMES		FACILITY NUMBER:	306001500
ADMINISTRATOR:	BEACH, TRISH		FACILITY TYPE:	740
ADDRESS:	2575 COLUMBIA DRIVE		TELEPHONE:	(714) 549-9380
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 6	DATE:	10/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Trish Beach, Columba Majuelo		TIME COMPLETED:	03:45 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 10/12/2022 at 9:55am, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to Beach Homes. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on Infection Control. At 10:08am, LPA Cho was greeted by Caregiver Columba Majuelo. Due to resident only street parking requirements, LPA inquired Caregiver Majuelo where LPA can park and was instructed to park on the driveway at Beach Homes II across the street. At 10:10am, LPA entered the facility and completed the Coronavirus 2019 (COVID-19) screening procedure. As of today, there are no active COVID-19 cases in the facility. LPA observed Caregiver Marilen Galafate Calma was also present and on duty. Administrator (Admin) Trish Beach arrived at the facility at 10:17am. Facility screens and documents temperatures for visitors on a sign in sheet. Facility does not document daily temperatures of staff and residents. Admin and caregivers were informed to document residents and staff temperatures daily. In addition, it was brought to the Admin's attention that Caregiver #1 (C1) was not fingerprint cleared therefore is not eligible to work at this facility. S1 was instructed to leave the facility, and LPA observed S1 leaving the facility at 3:06pm. LPA observed temperatures are also taken daily for residents and staff. LPA observed the required COVID-19 precautionary signs posted on the front door. The Complaint Poster (PUB475) met the size requirement. The facility is licensed for six non-ambulatory residents and has a hospice waiver for four. There are currently six residents living in the facility of which two are in hospice care. At 10:25am, LPA Cho conducted a tour of the physical plant along with Admin Beach. The single story home consists of seven resident bedrooms and six resident bathrooms. There is one staff private bedroom and one guest bathroom. The facility also has a living room, dining area, kitchen, and an attached two-car garage with laundry. LPA inspected seven resident bedrooms. The resident bedrooms had the required furnishings. LPA observed a camera on the dresser of Resident #1 (R1). Per Admin, Admin was unaware the camera was in place. Admin indicated that there is no use of the camera, and the camera was removed during the visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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 7

Document Has Been Signed on 10/12/2022 03:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BEACH HOMES	FACILITY NUMBER: 306001500
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interviews, one out of two staff were not fingerprint cleared prior to employment which poses an immediate Health, Safety, or Personal Rights risk to persons in care. CIVIL PENALTY ASSESSED.
	POC Due Date: 10/13/2022
	Plan of Correction
1 2 3 4	Administrator agrees to obtain an exemption and receive clearance for S1 to be eligible to work and to provide proof by POC due date via email to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC809 (FAS) - (06/04)

Page: 6 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BEACH HOMES	FACILITY NUMBER: 306001500
	VISIT DATE: 10/12/2022

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

The resident bathrooms were checked. The toilets worked properly, grab bars were secure, the showers were free of mold/mildew, and non-skid mats were in place. Resident bath towels and personal hygiene and incontinence supplies were adequately stocked including paper towels and hand soaps. LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperature and the water temperatures measured at 108.6 degrees Fahrenheit in the Bathroom #1, 116.9 degrees Fahrenheit in Bathroom #2, 117.6 degrees Fahrenheit in Bathrooms #3 and #4, 115.7 degrees Fahrenheit in Bathroom #5, and 116.2 degrees Fahrenheit in Bathroom #6. LPA Cho inspected the kitchen. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was mounted, fully charged, and serviced on 03/09/2022. At 12:46pm, the smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. No bodies of water was found, and there was shading and sufficient seating for residents in the backyard. Walkways around the home were clear of hazards, and there were no security bars or weapons on the premises. The exit side gate was self-closing and self-latching. LPA reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility to update the information using the current LIC610E form per the Provider Information Notice (PIN 22-02-ASC) released on 01/06/2022. LPA observed sufficient supply of emergency food/water and PPEs. The first aid kit met all the required components except a first aid manual.

LPA provided the following guidance: to document residents and staff temperatures daily, to update Emergency and Disaster Plan (LIC610E) using the current form, to obtain a first aid manual, discussed the use of a camera in a resident's bedroom, to provide documentation for S1's start date via email, and Admin was also reminded the importance of staying abreast with CCLD’s COVID-19 guidance and additional information by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov. At 3:03pm, Administrator Trish Beach confirmed via text designating Caregiver Columba Majuelo to sign the report on behalf of the Admin.

Based on the observations made during today's visit, a deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations, therefore an immediate CIVIL PENALTY is assessed. Advisory Notes (LIC9102) were issued during the visit. An exit interview was conducted with Caregiver Columba Majuelo, and a copy of this report (LIC809, LIC809C, LIC809D, LIC421BG, LIC9102s, LIC811s along with the appeal rights) were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC809 (FAS) - (06/04)

Page: 7 of 7