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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002908
Report Date: 07/29/2021
Date Signed: 07/29/2021 01:02:48 PM

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 IIFACILITY NUMBER:
306002908
ADMINISTRATOR:TRISH BEACHFACILITY TYPE:
740
ADDRESS:2572 COLUMBIA DRIVETELEPHONE:
(714) 549-5877
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 6DATE:
07/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Care staff Diana SanchezTIME COMPLETED:
12:20 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 Diana Sanchez 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. There are six (6) residents and two (2) employees present.
In addition, LPA Frank tested the hot water temperature, which measured 112.8 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.

LPA Frank reviewed the following documents : 1.) Designation of Administrative Responsibility (LIC308) 2.) Personnel Report (LIC500); 3.) Emergency Disaster Plan (LIC610E); 4.) Current Liability Insurance, (LIC 808) Mitigation Plan.

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: 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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