306005597-8-26-2024-22-AS-JROO-D8HUHN-20240826153612

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005597
Report Date: 08/26/2024
Date Signed: 08/26/2024 03:36:18 PM

Document Has Been Signed on 08/26/2024 03:36 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:	COAST SENIOR CARE 3		FACILITY NUMBER:	306005597
ADMINISTRATOR:	VIANA, KRISTEN		FACILITY TYPE:	740
ADDRESS:	6822 MARILYN DR		TELEPHONE:	(714) 470-0194
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY:	6	CENSUS: 6	DATE:	08/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Caregiver, Renato Galdones		TIME COMPLETED:	03:45 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 8/26/2024, Licensing Program Analysts (LPA) Janette Romero and Debbie Palacios conducted an unannounced visit to the facility for a required annual inspection. LPAs met with Caregiver, Renato Galdones who was informed of the purpose of the visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents and an approved hospice waiver for four (4). LPAs were informed none of the residents at the facility are on hospice. During today's visit, there was six (6) residents and two (2) staff present. LPA Palacios toured the facility with Caregiver Galdones and observed the facility is made up of a one-story home with six (6) resident bedrooms, three (3) bathrooms, one (1) staff room, a kitchen, dining room, living room, and attached garage. During the tour, Caregiver Galdones tested three (3) of the smoke alarms/carbon monoxide detectors and LPA observed them to be operational. LPA also observed a charged fire extinguisher placed near the kitchen. Indoor and outdoor passageways were free of obstruction. The facility has outdoor shaded seating for the residents in care. There were no bodies of water observed on the premises. Medications are secured in a locked dining room cabinet. Resident bedrooms had the required furniture and lighting. Bathrooms had grab bars near the toilet and in the showers. LPA toured the kitchen and observed the facility had more than a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Resident files reviewed had signed admission agreements and residents with a dementia diagnosis had updated physician reports. Staff present have a criminal record clearance and valid first aid/CPR certification. During a record review, LPAs reviewed Resident 1's (R1's) Physician's Report's (LIC 602A's) dated 11/28/23 which indicates R1 is bedridden and unable to independently transfer themselves to and from bed.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

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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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: COAST SENIOR CARE 3	FACILITY NUMBER: 306005597
	VISIT DATE: 08/26/2024

NARRATIVE

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LPAs interviewed R1, who reported they are unable to reposition themselves or transfer themselves to and from bed. LPAs reviewed R1's Preplacement Appraisal Information LIC 603 dated 4/22/24 which indicates R1 is unable to move their arms and legs, and requires maximum assistance to move to and from bed. Interviews conducted reveled R1 is repositioned every two (2) hours.

Based on the aforementioned, the facility is in violation of their approved fire clearance. An exit interview was conducted and this report was reviewed and provided to Caregiver Renato. along with a Confidential Names List (LIC 811), LIC809-D and LIC421M and appeal rights.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/26/2024 03:36 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: COAST SENIOR CARE 3	FACILITY NUMBER: 306005597
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews conducted and records reviewed, the licensee did not comply with the section cited above by accepting/retaining a bedridden resident while having a fire clearance for six (6) non-ambulatory residents only, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/27/2024
	Plan of Correction
1 2 3 4	Licensee will contact their local fire department and inform them the facility has a bedridden resident. R1 will be relocated to a facility that has an approved bedridden fire clearance. POC to be submitted to LPA by close of business on 8/27/2024.

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.

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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