<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003705
Report Date: 07/09/2024
Date Signed: 07/12/2024 09:19:39 AM

Document Has Been Signed on 07/12/2024 09:19 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:COACHMAN HOMEFACILITY NUMBER:
306003705
ADMINISTRATOR/
DIRECTOR:		RAFAEL TORRESFACILITY TYPE:
735
ADDRESS:9333 COACHMAN AVENUETELEPHONE:
(310) 567-9285
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 6CENSUS: 3DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:Jacqueline Mikin, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:55 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
Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Administrator, Jacky Mikin, who allowed entry into the facility and assisted with the visit.

LPA Rea and Ms. Mikin toured the facility inside and out, reviewed food supply, reviewed staff files, reviewed resident files, and reviewed resident medications.

Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathrooms are clean, and showers have non-skid materials. The hot water temperature measured at 130.1 degrees F in kitchen. Water temperature was not measured in bathroom, due to client(s) using the bathroom. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors located throughout the facility, tested and operational. Carbon monoxide detector was also observed, tested and operational. LPA observed a sufficient supply of PPE. LPA observed a sufficient amount of perishable and non-perishable food on today's visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies were observed during the visit. Deficiencies cited on 809-D. Exit interview held, copy of the report and appeal rights were provided to Ms. Mikin.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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 2
Document Has Been Signed on 07/12/2024 09:19 AM - It Cannot Be Edited


Created By: Angelica Rea On 07/09/2024 at 03:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: COACHMAN HOME
FACILITY NUMBER: 306003705

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)


This requirement is not met as evidenced by: LPA Rea observed that the water temperature measured at 130.1 on today's visit.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 1 out of 1 sinks measured which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2024
Plan of Correction
1
2
3
4
Administrator will ensure that the water temperature is corrected to measure between 105 degrees F and 120 degrees F, as required.
Type A
Section Cited
CCR
80025(b)


This requirement is not met as evidenced by: LPA Rea observed that the facility does not have a current surety bond at the facility. Administrator was unsure if the facility has a current surety bond.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
1
2
3
4
Administrator will send LPA Rea a copy of facility surety bond by POC due date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2