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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005619
Report Date: 07/22/2021
Date Signed: 09/01/2021 08:24:18 AM

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:COASTAL SENIOR LIVINGFACILITY NUMBER:
306005619
ADMINISTRATOR:KOSLA, FRANCINEFACILITY TYPE:
740
ADDRESS:27202 PASEO PEREGRINOTELEPHONE:
(949) 525-7434
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:6CENSUS: 1DATE:
07/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:49 PM
MET WITH:Salma AguirreTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA was greeted and granted entry by Caregiver Salma Aguirre. LPA and Caregiver toured the facility. Facility is a two story, 5 bedroom, 5 bathroom home with an attached garage. The garage is used for storage and kept locked. LPA observed the fireplaces upstairs and downstairs are both screened. Smoke detectors/carbon monoxide detectors tested operational. All bedrooms had the required furnishings and have ample space to accommodate the resident's belongings. LPA observed the kitchen is clean and organized and had 2 day perishable and 7 day non-perishable food supply on hand. LPA toured the backyard. No bodies of water observed. Exit gate is operational. Mitigation plan has been submitted. Mitigation plan is pending approval. No deficiencies are being cited as a result of this visit. An exit interview was conducted and copy of the report provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021
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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