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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005495
Report Date: 05/15/2024
Date Signed: 05/15/2024 04:24:45 PM


Document Has Been Signed on 05/15/2024 04:24 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
ORANGE COUNTY ASC, 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:
05/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Samantha Chiascione - AdministratorTIME COMPLETED:
04:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility unannounced for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by Administrator Samantha Chiascione.

The facility is a one-story home with six resident bedrooms, seven bathrooms, kitchen, dining room, living room, staff room, backyard and attached 2-car garage. LPA observed residents lounging in their rooms and in the backyard, receiving therapy or interacting with staff.

All resident rooms had the required elements, including bed, chair, closet space and ample lighting.
Facility has extra linens for residents in the living room cabinets. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water in bathrooms measured between 105 and 120 degrees Fahrenheit. Two bathrooms' hot water were measured close to 120 degrees Fahrenheit. LPA advised facility maintain a water log as the warmer months approach. LPA observed facility has emergency food and water supply. LPA noted Fire Extinguishers were last serviced on 5/8/2024. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in cabinets in the kitchen and garage. Knives are locked up separate from toxic chemicals. Medication for each client is kept locked in a cabinet in the living room. Exit gate is unlocked and self latching. LPA reviewed resident and staff files. LPA interviewed three staff and one resident.

Based on record review, LPA observed the facility has not conducted quarterly disaster drills in the last year. A deficiency is being issued.

Based on today's inspection, one deficiency is being issued. An exit interview was conducted and a copy of


this report and appeal rights were provided to the facility.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
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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Document Has Been Signed on 05/15/2024 04:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: BEACH HOMES III

FACILITY NUMBER: 306005495

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 05/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above due to having no record of disaster drills conducted in the last year, which poses a potential safety risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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AD stated they wll conduct a disaster drill, document and submit proof of the completed drill to LPA via email by the assigned POC due date of 5/29/24
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L MasonTELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2024
LIC809 (FAS) - (06/04)
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