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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005690
Report Date: 02/18/2022
Date Signed: 02/18/2022 02:46:29 PM

Document Has Been Signed on 02/18/2022 02:46 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ASSISTED COASTAL LIVINGFACILITY NUMBER:
306005690
ADMINISTRATOR:RUTH KHAYFACILITY TYPE:
740
ADDRESS:25011 MONTE VERDE DRIVETELEPHONE:
(949) 413-4069
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY: 6CENSUS: 6DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Nelson CapatiTIME COMPLETED:
03:01 PM
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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 explained the reason for the visit. Staff contacted the Administrator Ruth Khay via cellphone and informed her of the visit. LPA spoke with the Administrator Ruth Khay and explained the reason for the visit. LPA informed the Administrator it was not required for her to be present during the visit. Ruth Khay acknowledged the information and stated she would not attend the visit. LPA informed the Administrator she would be contacted if the LPA had any questions, call ended. LPA and staff toured the facility. The facility is a single story home with 7 bedrooms, 6 bathrooms and an attached two car garage. 1 bedroom is for staff and 6 are for residents. LPA observed all resident bedrooms had the required furniture and were clean and organized. All 6 bathrooms were clean and operational. Hot water temperature in all 6 bathrooms measured between 112 degrees Fahrenheit and 114.2 degrees Fahrenheit. All smoke/carbon monoxide detectors tested operational. The fireplace in the living room has been sealed with drywall and painted. LPA observed the See something, say something poster, PUB 475, is in the dining room and does not measure 20" X 26" inches, it is smaller measuring 11" X 17" inches. LPA observed there is a 2 day perishable and 7 day non-perishable food supply on hand in the kitchen. The kitchen is clean and organized. All 4 stove burners light unassisted. LPA and staff toured the garage. There is a laundry room on the side of the kitchen which leads to the garage. LPA observed the washer and dryer in the laundry room. The fire extinguisher in the laundry room is fully charged. The garage is kept locked and inaccessible to residents. The garage is used for storage of food and supplies. LPA and staff toured the backyard. No bodies of water observed. There is a table with an umbrella and chairs to sit outside. The side exit gate is operational. There is a gate that is kept locked that leads to a path down the side of the hill up to the property line. Staff reported the gate is kept locked and no one uses the path to go down the side of the hill. No obstacles or hazards observed in the backyard. Facility has a mitigation plan that is pending review. No deficiencies are being cited as a result of this visit. An exit interview was conducted and a copy of the report provided.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2022
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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