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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005619
Report Date: 07/07/2022
Date Signed: 07/07/2022 11:54:14 AM


Document Has Been Signed on 07/07/2022 11:54 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
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: 5DATE:
07/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Ahmad AliTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection (mitigation). LPA was greeted and granted entry by staff. LPA met with Administrator Ahmad Ali. LPA explained the reason for the visit. LPA observed the PUB 475 poster is 8 1/2 by 11 inches. LPA and Administrator toured the facility. The facility has an upper and lower level. The main entry is in the middle. The front door opens to a landing with stairs leading up and down to each level. The bottom level has 4 bedrooms, one is for staff, 3 bathrooms, a storage closet, living room with a screened fireplace, an entrance to the garage and a French door leading to the patio. Hot water measured between 132.2 degrees Fahrenheit and 136.0 degrees Fahrenheit. Smoke detectors/carbon monoxide detectors tested operational. LPA observed the ramp outside the lower level living room door leading to the backyard patio is chipped and cracked. LPA toured the backyard. No bodies of water observed. Exit gate is operational. No obstacles or hazards observed in the backyard. The 2 car garage is used for storage and kept locked, LPA and Administrator toured the upper level of the facility. The upper level has 2 bedrooms, 2 bathrooms, kitchen, dining room and a living room with a screened fireplace. LPA observed all bedrooms had the required furnishings. LPA observed the kitchen is clean. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand. No obstacles or hazards observed in the facility. LPA consulted with the Administrator concerning continued Covid-19 mitigation procedures and reporting requirements. Deficiencies are being cited per California Code of Regulations, Title 22, Division 6, Chapter 8. An exit interview was conducted and a copy of this report as well as appeal rights were discussed and provided to the Administrator.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
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 07/07/2022 11:54 AM - 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: COASTAL SENIOR LIVING
FACILITY NUMBER: 306005619

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)

Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degreesF.
Deficient Practice Statement
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This requirement is not met as evidenced by, LPA measured the hot water in 3 bathrooms at 132.2 degrees Fahrenheit to 136.0 degrees Fahrenheit. This poses a potential health and safety risk to residents in care.
POC Due Date: 07/10/2022
Plan of Correction
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Licensee states the hot water temperature will be adjusted to meet the regulation requirements. Licensee states a hot water temperature log will be used daily to track the hot water temperature to avoid future issues with the water temperature.
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: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: (951) 473-7041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2022
LIC809 (FAS) - (06/04)
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