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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005495
Report Date: 03/30/2022
Date Signed: 03/30/2022 04:21:41 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/30/2022 04:21 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 IIIFACILITY NUMBER:
306005495
ADMINISTRATOR:BEACH, ANDYFACILITY TYPE:
740
ADDRESS:2336 COLLEGE DRTELEPHONE:
(714) 549-1905
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY:6CENSUS: 6DATE:
03/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:Trish Beach, AdministratorTIME COMPLETED:
03:55 PM
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 On today's date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Rosie Quiroz was greeted, COVID-19 screened and granted entry into the facility by caregiver Brenda De Leon. LPA Rosie Quiroz explained the nature of the visit to Caregiver 2 (CG2). On or about 2:55pm Administrator Trish arrived to facility.

On or about 2:44pm, LPA Rosie Quiroz along with Caregiver 2 (CG2) began the tour of the inside and outside of the facility. There are six residents in care and there are no active Covid-19 cases in the facility. LPA Rosie Quiroz observed three of six residents in living room area watching television and relaxing, and three of six residents in their bedrooms relaxing. 6 of 6 residents appeared to be clean and well taken care of. LPA observed a check in station in the entry of the facility. LPA observed required department postings, Covid-19 precautionary postings in the facility as well as hand washing signs throughout the facility. All restrooms observed to have a supply of soap and appeared to be clean. LPA inspected resident’s bedrooms and appeared to be clean. All bedrooms observed to have all required components. LPA Rosie Quiroz observed the emergency and disaster and evacuation plan. Facility has a supply of emergency food and water in attached garage. LPA observed the PPE supply in the facility readily available for use. LPA toured the outside of the facility and observed seating are for resident’s enjoyment. The facility has completed the LIC808 Mitigation Plan. The plan was reviewed and approved by the Department on April 30, 2021. LPA was informed that all residents and staff have had their COVID-19 vaccinations.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with Administrator Trish Beach, and a copy of this report was provided via email.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
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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