306005495-2-20-2025-22-AS-FARS-DE435H-20250220165647

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005495
Report Date: 02/20/2025
Date Signed: 02/20/2025 05:03:12 PM

Document Has Been Signed on 02/20/2025 05:03 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	BEACH HOMES III		FACILITY NUMBER:	306005495
ADMINISTRATOR/ DIRECTOR:	BEACH, ANDY		FACILITY TYPE:	740
ADDRESS:	2336 COLLEGE DR		TELEPHONE:	(714) 549-1905
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	02/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:25 AM
MET WITH:	Julius Sevilla		TIME VISIT/ INSPECTION COMPLETED:	05:17 PM

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	On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 4 residents and the home currently has 6 residents, with 3 residents on hospice. Administrators (ADs) Julius Sevilla and Sandy Sevilla arrived shortly to conduct facility tour. Licensee Andy Beach arrived later during the visit. LPA along with AD toured the facility at 9:45 AM. LPA toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 6 resident bedrooms, living room, dining room, staff room and kitchen as well as 7 bathrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 112.2 degrees F and 118 degrees F in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit. LPA toured the kitchen at 9:50am and observed sharps unlocked in a slightly ajar drawer in the kitchen unsupervised during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. At 10:20am, LPA observed laundry detergent in an unlocked cabinet by the washer and driver and on the floor. LPA observed opened bottles of drinking alcohol and milk of magnesia in an unlocked refrigerator in the garage. The door access to the garage in unlocked. Prescription toothpaste was observed in resident 2's bathroom. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. The last disaster drill was conducted on 5/21/2024. Outside grounds were toured. One out of two exit gate walkways has gravel on the path throughout. Exit gates are unlocked and operational. CONTINUED ON LIC 809C DATED 2/20/2025.

Alisa Ortiz	TELEPHONE: (714) 287-4084
Fred Arias	TELEPHONE: (714) 703-2840
	DATE: 02/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

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 02/20/2025 05:03 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BEACH HOMES III	FACILITY NUMBER: 306005495
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, sharps were in an unlocked drawer unattended in the kitchen. In addition,laundry detergent was in an unlocked cabinet and on the floor in the garage by the washing machine. The door access to the garage is unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2025
	Plan of Correction
1 2 3 4	Facility locked the sharps drawer and locked and put away the laundry detergent during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Alisa Ortiz	TELEPHONE: (714) 287-4084
Fred Arias	TELEPHONE: (714) 703-2840
	DATE: 02/20/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/20/2025 05:03 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BEACH HOMES III	FACILITY NUMBER: 306005495
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87307(d)(6)

Personal Accommodations and Services

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, one out of two outdoor exit gates has a pathway filled in with gravel. This could prevent residents from exiting the facility through one of the gates which poses a potential health and safety risk to persons in care.
	POC Due Date: 03/20/2025
	Plan of Correction
1 2 3 4	Facility to look at replacing gate with a wall and getting a new fire clearance.

Type B

Section Cited

CCR

87309(c)

Storage Space and Access

(c) Except as specified in subsection (d), the licensee shall implement reasonable interventions in order to ensure that nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies, are stored so as not to pose a hazard to residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, drinking alcohol was found in an unlocked refrigerator in the garage. The door way to the garage is unlocked which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/28/2025
	Plan of Correction
1 2 3 4	Facility disposed of the alcohol during the visit.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Alisa Ortiz	TELEPHONE: (714) 287-4084
Fred Arias	TELEPHONE: (714) 703-2840
	DATE: 02/20/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/20/2025 05:03 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BEACH HOMES III	FACILITY NUMBER: 306005495
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on LPA record review, the last disaster drill was conducted on 5/21/2024 which poses a potential safety risk to persons in care.
	POC Due Date: 02/28/2025
	Plan of Correction
1 2 3 4	Facililty to conduct disaster drill on 2/22/2025 and email LPA proof of drill.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Alisa Ortiz	TELEPHONE: (714) 287-4084
Fred Arias	TELEPHONE: (714) 703-2840
	DATE: 02/20/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

Page: 4 of 9

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BEACH HOMES III	FACILITY NUMBER: 306005495
	VISIT DATE: 02/20/2025

NARRATIVE

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There are no security bars or weapons on the premises. First aid kit contained all required items except tweezers. Facility conducts activities in the form of exercise. There is shaded outdoor seating for residents. LPA observed the emergency food and water supply. LPA reviewed six resident files and two staff files.

All resident files contained required documentation including admission agreements, physician reports, and resident appraisals. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPA reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order. Some medications were observed stored in a daily pill box.

Based on the observations made during today’s visit, the following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Fred Arias	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

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