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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005784
Report Date: 05/08/2023
Date Signed: 05/09/2023 07:14:12 AM


Document Has Been Signed on 05/09/2023 07:14 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 LIVINGFACILITY NUMBER:
306005784
ADMINISTRATOR:SHARIFAN, MONELIFACILITY TYPE:
740
ADDRESS:14352 MERVYN PLACETELEPHONE:
(714) 852-3535
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:6CENSUS: 6DATE:
05/08/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jefferson AgustinTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Lydia Martinez conducted an unannounced Case Management visit to the facility. LPA was greeted and granted entry by Staff Jefferson Agustin after temperature was taken. LPA explained the reason for visit. Staff Agustin contacted facility Administrator (AD) Moneli Sharifan and left a message notifying her of LPA's presence at the facility.

Licensee submitted a request to add resident bedroom #1 as bedridden. Fire Inspection Request was submitted on 03/13/2023. Orange County Fire Authority granted Fire clearance for Bedroom #1 as Bedridden on 03/29/2023. Per Staff, facility has no Bedridden residents.

LPA Martinez observed a total of 2 Staff on duty and 6 residents in care, of which 3 are on hospice. Facility is now licensed for 5 non-ambulatory, 1 ambulatory residents, of which 1 may be bedridden. Facility has a Hospice Waiver for 6 residents.

On today's visit, LPA Martinez conducted a tour of the interior and exterior of the facility with Staff Agustin. There were no deficiencies noted during today's visit per the California Code of Regulations, Title 22, Division 6, Chapter 8.

An exit interview was conducted with Staff Agustin and a copy of this report will be sent to email on file.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Lydia MartinezTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2023
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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