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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004237
Report Date: 06/20/2022
Date Signed: 06/20/2022 02:19:11 PM


Document Has Been Signed on 06/20/2022 02:19 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:SOUTH COAST MANOR CFACILITY NUMBER:
306004237
ADMINISTRATOR:PAVEL & LEONTINA BALOSFACILITY TYPE:
740
ADDRESS:10452 MILDRED AVENUETELEPHONE:
(714) 583-8031
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY:4CENSUS: 1DATE:
06/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Tina BalosTIME COMPLETED:
12:22 PM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Administrator/ Licensee Tina Balos and explained the reason for the visit. Licensee Pavel Balos was present as well.

At 11:15 AM, LPA toured the facility with Administrator Balos. There is one resident in care during today's visit. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the entrance of the facility. Facility has covid precaution postings as well as all required department postings. Administrator Balos has an administrator certificate expiring on 01/23/2023. Facility has completed the mitigation plan. LPA observed adequate emergency food and water as well as the first aid kit which contained all required items. LPA toured the outside grounds and observed ample shaded outside visitation area. Smoke detectors tested operational during today's visit. LPA observed the locked medication storage area. Facility has ample supply of PPE and cleaning supplies. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. Resident is vaccinated for covid-19.

LPA consulted with Administrator regarding the infection control plan due 06/30/2022 and provided the PIN with a template for the plan.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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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