306005784-4-29-2022-22-AS-AMEL-CDWU2B-20220428151139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005784
Report Date: 04/28/2022
Date Signed: 04/29/2022 08:04:36 AM

Document Has Been Signed on 04/29/2022 08:04 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:	SILVER COAST LIVING		FACILITY NUMBER:	306005784
ADMINISTRATOR:	SHARIFAN, MONELI		FACILITY TYPE:	740
ADDRESS:	14352 MERVYN PLACE		TELEPHONE:	(714) 852-3535
CITY:	TUSTIN	STATE: CA	ZIP CODE:	92780
CAPACITY:	6	CENSUS: 6	DATE:	04/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:02 PM
MET WITH:	Mary-Joy and Charlie Bernardo, Caregivers		TIME COMPLETED:	03:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA)Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Charlie Bernardo and Mary Joy Bernardo and explained the reason for the visit. At 2:02pm Administrator Moneli Sharifan arrived. At 1:06 PM, LPA toured the facility with Caregiver Mary Joy . Facility is 5 bedroom, 2 bathroom single story home with a detached garage, Facility has 6 residents present during today's visit. LPA observed residents relaxing in the facility. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility uses a handwritten sign in/ questionnaire. Facility takes residents and staff temperatures daily and documents. The facility mitigation plan has been completed and approved. LPA observed emergency food and water. LPA observed locked medication cabinet. LPA toured the outside grounds and observed outside shaded visitation area. Exit gate is unlocked and self latching. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. LPA observed a 4 weeks supply of PPE. LPA reviewed all residents files and all contained required documentation including updated emergency information.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

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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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: SILVER COAST LIVING	FACILITY NUMBER: 306005784
	VISIT DATE: 04/28/2022

NARRATIVE

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At 1:25pm during tour LPA observed the detached garage, when questioned caregiver Mary Joy stated garage was locked. Caregiver called administrator and placed administrator on speaker, LPA Mendivil was told there was no access to garage. LPA Mendivil was able to see into garage and observed a bed, trash can and alarm clock. LPA Mendivil advised caregiver to call administrator as access is needed. Caregiver called administrator and administrator was placed on speaker, LPA Mendivil advised that the garage had bedroom items and LPA Mendivil was told by administrator it was a break room. LPA Mendivil was granted access by caregiver Mary Joy. LPA observed a bed, clothing, medications, and a fridge. Caregiver Mary Joy knocked on a door in another part of the garage and caregiver Christopher Esma answered the door and stated was sleeping. LPA observed 2 beds in the other part of the garage.

LPA Mendivil advised Administrator to have keys present at facility during all shifts.

Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed and a copy of 809, 809-D ,LIC 421IM and appeal rights were provided.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/29/2022 08:04 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: SILVER COAST LIVING	FACILITY NUMBER: 306005784
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as evident by staff is utlizing two rooms in the garage which poses an immediate health and safety to persons in care.
	POC Due Date: 04/28/2022
	Plan of Correction
1 2 3 4	Licensee will provide written plan of action and forward to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Alisa Ortiz	TELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea Mendivil	TELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3