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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005413
Report Date: 02/23/2022
Date Signed: 02/23/2022 01:58:49 PM


Document Has Been Signed on 02/23/2022 01:58 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:COAST SENIOR CARE 2FACILITY NUMBER:
306005413
ADMINISTRATOR:VIANA, KRISTENFACILITY TYPE:
740
ADDRESS:11861 LORALEEN STREETTELEPHONE:
(714) 583-8067
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 6DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Licensee Kristen Viana TIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into the facility by Licensee Kristen Viana and explained the reason for the visit.

LPA Frank toured the facility. There are 6 residents residing in the facility and no active COVID-19 cases. LPA observed 5 residents on site, 1 resident went to day program. All residents appeared clean and well taken care of. LPA observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed had ample soap/ sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all required components. Facility is taking residents temperatures and documenting results.
LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies. Facility has completed the LIC 808 Mitigation Plan.
In addition, LPA Frank tested the hot water temperature, which measured 118.3 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 observe the facility to be clean and in good repair.
LPA Frank reviewed : 1.) Emergency Disaster Plan (LIC610E); 2 ) LIC 9020A Client Roster; LIC 808)
Mitigation Plan and 3) Current Liability Insurance, Designation of Administrative Responsibility (LIC308) and
Personnel Report (LIC500);
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: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
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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