306005597-4-8-2025-22-AS-WVAS-DFJQ6B-20250408115317

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005597
Report Date: 04/08/2025
Date Signed: 04/08/2025 11:53:26 AM

Document Has Been Signed on 04/08/2025 11:53 AM - 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/ DIRECTOR:	VIANA, KRISTEN		FACILITY TYPE:	740
ADDRESS:	6822 MARILYN DR		TELEPHONE:	(714) 470-0194
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	04/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Renado Galdones		TIME VISIT/ INSPECTION COMPLETED:	11:45 AM

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	Licensing Program Analyst (LPA) William Vanegas made an unannounced inspection for the purposes of conducting an annual inspection. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Care Giver (CG) Alice Magee. LPA Vanegas set up equipment and began a tour of the facility and observed the following. This is a one storied home with an attached two car garage, five bedrooms, and two and a half bathrooms, all which are available for resident use, and staff use. LPA Vanegas observed the kitchen area to be clean and free of debris, LPA Vanegas observed a gas stove, microwave, refrigerator, dishwasher, washer, and dryer to all be in good repair, and tested operational. LPA Vanegas observed a two day supply of perishable food, and a seven day supply of non-perishable food along with a sufficient amount of emergency water on hand for residents in care, and staff on duty. LPA Vanegas observed all client rooms to have the required furnishings such as a bed, lamp, chest drawer, clean linens in good repair, meaning no strains or tears, and enough storage space for personal belongings. Rooms are large enough to walk about freely, and no obstructions are blocking the entry way. LPA Vanegas observed bathrooms to be clean and free of any mildew and debris. Toilets and water faucets tested operational, and restrooms had all required furnishings such as grab bars, shower chairs, and slip resistant floor matts. Water tested between 115.5 and 117.5 degrees. CONTINUED ON LIC809C

Armando J Lucero	TELEPHONE: (714) 703-2866
William Vanegas	TELEPHONE: (714) 497-7621
	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 04/08/2025

NARRATIVE

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LPA Vanegas reviewed six resident files, and two staff files, all files (staff and resident) contained the correct documentation and were filed correctly. LPA Vanegas reviewed all medications with CG Renado Galdones. Per LPA Vanegas review all medications are being administered per physicians orders. All medications are being documented correctly as well.

LPA Vanegas toured the outside of the facility and observed the following. There is a large backyard with an outdoor shaded sitting area, and the backyard is large enough to participate in outdoor activities upon resident request. No obstructions were observed a long the exit routes, and side doors are self latching and unlocked.

LPA Vanegas observed all smoke and carbon monoxide detectors to be operational and in good repair. LPA Vanegas observed all fire extinguishers to be fully charged and up to date. LPA Vanegas observed there to be cameras in the kitchen area, and along the two hallways of the facility. LPA Vanegas advised that recording can only be visual and not audio, LPA Vanegas advised that a sign stating that individuals are being recorded must be posted in the entry way of the facility.

Based on observations made during today's inspection no deficiencies will be cited per title 22 chapter 8 division 6 of the California Code of Regulations. An exit interview was conducted with CG Renado Galdones and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2866
LICENSING EVALUATOR NAME: William Vanegas	TELEPHONE: (714) 497-7621
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025

LIC809 (FAS) - (06/04)

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