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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002908
Report Date: 09/08/2022
Date Signed: 09/08/2022 03:06:49 PM


Document Has Been Signed on 09/08/2022 03:06 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 IIFACILITY NUMBER:
306002908
ADMINISTRATOR:TRISH BEACHFACILITY TYPE:
740
ADDRESS:2572 COLUMBIA DRIVETELEPHONE:
7145495877
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 6DATE:
09/08/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:04 PM
MET WITH:Elsa Roman - Assistant AdministratorTIME COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Beach Homes II. LPA Velazquez was allowed entry into the facility and initially met with Caregiver Adonimar Venturina. Assistant Administrator (AA) Elsa Roman arrived shortly after LPA's arrival. Upon entering the facility LPA Velazquez observed the 2 Caregivers present were not wearing face masks as mandated. The purpose of today's Case Management visit was to follow-up on COVID-19 reporting to the Department.


At 2:32 PM LPA Velazquez along with AA Roman conducted a tour of the facility to look in on the 6 residents in care. The residents in care appeared well-groomed and well-cared for and there were no immediate health and safety issues observed. LPA Velazquez reviewed Title 22 Regulation Section 87211 Reporting Requirements with AA Roman. AA Roman made a copy of said regulation.



Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted with Assistant Administrator Elsa Roman and a copy of this report along with the appeal rights and LIC 9098 were provided at the time of this visit.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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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Document Has Been Signed on 09/08/2022 03:06 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 II
FACILITY NUMBER: 306002908

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2022
Section Cited

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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by: based on observation and interview the Licensee did not notify the Department of the COVID-19 cases in the facility. This poses a potential risk to the health & safety of residents 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: Sheila SantosTELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
LIC809 (FAS) - (06/04)
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