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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005619
Report Date: 07/07/2025
Date Signed: 07/07/2025 04:16:40 PM

Document Has Been Signed on 07/07/2025 04:16 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/
DIRECTOR:
AHMAD ALIFACILITY TYPE:
740
ADDRESS:27202 PASEO PEREGRINOTELEPHONE:
(949) 538-6547
CITY:SAN JUAN CAPISTRANOSTATE: CAZIP CODE:
92675
CAPACITY: 6CENSUS: 3DATE:
07/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Ahmad AliTIME VISIT/
INSPECTION COMPLETED:
04:32 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 met with Administrator Ahmad Ali and explained the reason for the visit. The Administrator's certificate expires on May 4, 2026. Facility is licensed for 6 non-ambulatory of which 1 may be bedridden and a hospice waiver for 4. 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 first floor consists of the family room, laundry room, 3 bedrooms and 3 bathrooms and the garage. The garage is kept locked and used for storage. The second floor consists of 2 bedrooms, 2 bathrooms, the living room, dining room and the kitchen. LPA and Administrator toured the facility. LPA observed the See Something, Say Something poster (PUB 475) posted in the main entry way of the facility. LPA and the Administrator toured the first floor. LPA observed all resident rooms had the required furnishings. LPA observed all bathrooms are clean and operational. Hot water measured 107.7 in the bathrooms on the first level. LPA observed the garage is used to store extra supplies and furniture. The garage is kept locked. LPA observed the fire extinguisher at the base of the staircase is fully charged. No obstacles or hazards observed on the first floor. LPA and Administrator toured the second floor. LPA observed an emergency evacuation chair at the top of the staircase. LPA observed both resident rooms had the required furnishings. Both bathrooms are clean and operational. LPA observed a 2 day perishable and a 7 day non-perishable food supply on hand in the kitchen. The fire extinguisher in the kitchen is fully charged. LPA observed knives are kept locked in a kitchen drawer and medications are kept locked in the kitchen pantry. LPA observed the 5 burner gas stove lights unassisted. LPA did not observe and Administrator verified the facility does not have an internet device dedicated for resident use only.
Sheila SantosTELEPHONE: (714) 334-2062
Joseph AlejandreTELEPHONE: 714-705-6018
DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2025
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: COASTAL SENIOR LIVING
FACILITY NUMBER: 306005619
VISIT DATE: 07/07/2025
NARRATIVE
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Smoke detectors/carbon monoxide detectors tested operational. The signal system is operational. The last emergency drill was conducted on April 11, 2025. LPA reviewed 3 resident files. Resident 1 and Resident 3 did not have a current appraisal/needs and care plan. No other discrepancies noted. LPA reviewed 2 staff files. Staff 1 and Staff 2, each had 20 hours of training which included 8 hours of Dementia training, but it did not include 4 hours of training for, postural supports, restricted conditions and hospice care. No other discrepancies observed. Deficiencies are being cited per Title 22, Division 6 of the California Code of Regulations. An exit interview was conducted 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: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/07/2025 04:16 PM - It Cannot Be Edited


Created By: Joseph Alejandre On 07/07/2025 at 03:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COASTAL SENIOR LIVING

FACILITY NUMBER: 306005619

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 07/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out 2 staff files, Staff 1 and Staff 2 did not have 4 hours of training specific to psotrual supports, restricted health conditions, and hospice care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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Licensee agrees to train Staff 1 and Staff 2 on 4 hours of training specific to postural supports, restricted health conditions, and hospice care and submit proof of training to LPA by the POC due date.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out 3 staff files, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2025
Plan of Correction
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Licensee agrees to complete a new reappraisal (appraisal/needs and care plan) for Resident 1 and Resident 3 by the POC due date and to submit proof of correction to LPA.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (714) 334-2062
Joseph Alejandre
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: 714-705-6018
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2025


LIC809 (FAS) - (06/04)
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