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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005619
Report Date: 07/02/2024
Date Signed: 07/02/2024 04:12:26 PM


Document Has Been Signed on 07/02/2024 04:12 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:COASTAL SENIOR LIVINGFACILITY NUMBER:
306005619
ADMINISTRATOR:AHMAD ALIFACILITY TYPE:
740
ADDRESS:27202 PASEO PEREGRINOTELEPHONE:
(949) 525-7434
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY:6CENSUS: 4DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Ahmad AliTIME COMPLETED:
04:30 PM
NARRATIVE
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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 staff. LPA explained the reason for the visit. LPA and staff toured the facility. Facility is a two story home with 5 bedrooms, 5 bathrooms, living room, family room, dining room, kitchen, laundry room and an attached 2 car garage. Administrator Ahmad Ali arrived during the visit. The second floor consists of 2 bedrooms, 2 bathrooms, the living room, dining room and the kitchen. The first floor consists of the family room, laundry room, 3 bedrooms and 3 bathrooms. LPA and staff toured the second floor. LPA observed the fireplace in the living room is screened. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The 5 burner gas stove top lights unassisted. LPA observed the resident rooms on the second floor had the required furnishings and bed linens. Both bathrooms on the second floor are clean and operational. How water measured 107.0 degrees Fahrenheit in both bathrooms on the second floor. The smoke detectors and carbon monoxide detector tested operational on the first and second floors. LPA observed that all fire extinguishers are fully charged. LPA and staff toured the first floor. LPA observed the fireplace in the family room is screened. LPA observed the bedrooms on the first floor had the required furnishings and linens. LPA observed the emergency evacuation chair is kept in the entry way closet. The entry way to the facility is the landing for the stairway at the halfway point for the stairs going up to the second floor and down to the first floor. LPA observed the See Something, Say Something poster (PUB 475) posted in the family room. LPA observed all 3 resident rooms on the first floor had the required furnishings and bed linens. All 3 bathrooms on the first floor are clean and operational. Hot water measured 107.1 degrees Fahrenheit in bathroom 1 on the first floor. LPA observed that the laundry room has a bunk bed in it and is being used as a staff bedroom. LPA observed that bedroom number 5 which is next to the stairway has a walk in closet that has a bed in it and is being used as a staff bedroom. LPA toured the backyard. No bodies of water observed. The backyard has shaded seating for the residents. The exit gate is operational. LPA reviewed 2 staff files, no discrepancies observed. LPA reviewed 4 resident files and medication, no discrepancies observed.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 07/02/2024 04:12 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: COASTAL SENIOR LIVING
FACILITY NUMBER: 306005619

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(2)(B)
No room commonly used for other purposes shall be used as a sleeping room for any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above, LPA observed that the laundry room and the closet in bedroom 5 had beds in them and are being used as staff bedrooms, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
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Licensee agrees to remove the beds from both the laundry room and closet for bedroom 5 and not use them for staff bedrooms. Licensee agrees to read CCR 87307 and to sign a statement of understanding for the regulation and to forward proof to the LPA by the POC due date.
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: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: COASTAL SENIOR LIVING
FACILITY NUMBER: 306005619
VISIT DATE: 07/02/2024
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Deficiencies are being cited per title 22 Division 6 of the California Code of Regulations on the attached LIC 809D. An exit interview was conducted with the Administrator and a copy of the report provided along with appeal rights.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Joseph AlejandreTELEPHONE: 714-705-6018
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3