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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005850
Report Date: 09/29/2022
Date Signed: 09/29/2022 03:50:53 PM

Document Has Been Signed on 09/29/2022 03:50 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:COASTAL STAR CRISIS RESIDENTIAL CENTRALFACILITY NUMBER:
306005850
ADMINISTRATOR:WEST, RYANFACILITY TYPE:
772
ADDRESS:401 S. TUSTIN ST., BUILDING DTELEPHONE:
(714) 289-3936
CITY:ORANGESTATE: CAZIP CODE:
92866
CAPACITY: 15CENSUS: 13DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Administrator Ryan West and Program Director Ana RoblesTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Michelle Reed conducted an unannounced visit to the facility to conduct a Required 1 Year visit. The facility is licensed as a Crisis Residential Program with an average stay of 21 days. Upon arrival, LPA met with Ryan West. (COVID-19) screening procedures were conducted. There are currently no active COVID-19 cases in the facility. The facility staff screen and document temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The facility had an on-site program certification review by the Department of Health Care Services on 9/15/22 and found to be within compliance

At 1:15pm, LPA conducted a tour of the physical plant with Ryan West. The visit focused primarily on Infection Control. There were 13 clients present. .The facility is a two story building. There are 4 resident bedrooms downstairs and 4 upstairs. There are 4 bathrooms/showers for resident use. The facility also has a living room, dining area, kitchen, two activity rooms, 5 offices, and a laundry room and medication room. The client bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, and showers were free of mold/mildew. Client bath towels and personal hygiene supplies were adequately stocked including toilet paper, paper towels and hand soaps.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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: COASTAL STAR CRISIS RESIDENTIAL CENTRAL
FACILITY NUMBER: 306005850
VISIT DATE: 09/29/2022
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LPA observed hand washing signs. LPA tested the hot water temperature in the client bathrooms and the temperature measured at 115 degrees Fahrenheit.

LPA inspected the kitchen. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguishers were fully charged and serviced in 08/2022. The carbon monoxide detectors were tested and operational. Smoke detectors and sprinklers were last inspected on 8/24/22 by the City of Orange Fire Department. Medications, toxins, and sharps were locked and inaccessible to the clients.

LPA toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for clients. Walkways were clear of hazards. There is also a basketball court for resident use.



Facility has back-up emergency food and water supply. The First Aid Kits met all the required components, and the facility had sufficient PPEs. LPA discussed the Assembly Bill (AB) 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, residential care facilities for the elderly, and social rehabilitation facilities with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. The facility has an existing internet service and provides laptops and desktops.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
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: COASTAL STAR CRISIS RESIDENTIAL CENTRAL
FACILITY NUMBER: 306005850
VISIT DATE: 09/29/2022
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LPA reminded the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.

Based on the observations made during today's visit, no deficiencies cited in this review as per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Ryan West and a copy of this report was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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