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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005784
Report Date: 06/10/2024
Date Signed: 06/10/2024 04:06:09 PM


Document Has Been Signed on 06/10/2024 04:06 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:SILVER COAST LIVINGFACILITY NUMBER:
306005784
ADMINISTRATOR:SHARIFAN, MONELIFACILITY TYPE:
740
ADDRESS:14352 MERVYN PLACETELEPHONE:
(714) 852-3535
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:6CENSUS: 6DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jefferson Agustin, AD DesigneeTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to the facility today to conduct an Annual Required Evaluation. LPA was greeted and granted entry by Jefferson Agustin, Caregiver and Administrative (AD) Designee.

The facility is a single story building with five bedrooms and an approved fire clearance of five non-ambulatory residents of which one may be bedridden and six approved on hospice, The facility currently has a census of six residents in care with two on hospice.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors, testing hot water temperature in two of two resident bathrooms, and testing auditory devices on all exits. The hot water temperature measured between 110.4 and 111.7 degrees Fahrenheit and all smoke detectors were operational. The facility’s last fire drill was conducted on May 1, 2024. There is a pool in the backyard that is secured with fencing. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed medication storage and reviewed the centrally stored medications. Per review completed medication appear to be being given as prescribed.

LPA reviewed four of six staff training and fingerprint records. LPA reviewed and conducted a complete review of resident records. LPA interviewed one alert resident regarding her quality of care and spoke to staff present regarding care provided. LPA confirmed that administrator has a current administrator certificate which expires on May 13, 2025.

Based on the observations made during today’s visit, the facility appears to be in compliance with Title 22 Division 6 of the California Code of Regulations, no deficiency cited on this date. An exit interview was conducted with Jefferson Agustin, AD Designee and a copy of the report was given at the time of the visit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie RuppertTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
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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