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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005260
Report Date: 04/11/2022
Date Signed: 04/11/2022 11:25:13 AM


Document Has Been Signed on 04/11/2022 11:25 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:COAST SENIOR CAREFACILITY NUMBER:
306005260
ADMINISTRATOR:VIANA, KRISTENFACILITY TYPE:
740
ADDRESS:22201 CAPE MAY LANETELEPHONE:
(714) 377-0638
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 6DATE:
04/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Caregiver, Rey AvenaTIME COMPLETED:
11:45 AM
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) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted, granted entry into the facility by Staff and explained the reason for the visit.
.
During the visit at 9:30 AM LPA reviewed files. LPA reviewed 6 of 6 resident files. Residents emergency contact information and Physicians reports are current. LPA toured the facility at 9:52 AM. Facility is a 5 bedroom,(4 resident rooms ,1 staff bedroom) and 2 bathrooms single story home. LPA observed a sign in sanitization and temperature check station. Facility has required Department postings. LPA observed Emergency plan and personal rights posted. LPA toured resident rooms, Rooms contained required proper department furnishings. All restrooms observed contained a working water basin, soap, toilet paper and paper towels. Restrooms had proper hand washing signs posted. Residents were observed relaxing in common areas watching TV and relaxing in bedrooms. Facility has 1 fire extinguisher that is mounted and charged. Facility has small supply of PPE. LPA discussed importance of 30 day PPE supplies to Facility staff. Facility has 2 refrigerators and pantry with ample food supply. LPA observed facility has emergency food and water supply. Facility has secured location for toxins. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for Residents. Facility has several designated visitation areas. Facility has working alarms for entrance/exit doors and operating smoke detectors.

No deficiencies noted during todays visit. An exit interview was conducted with Caregiver Rey Avena and a copy of report was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2022
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 1