306005880-2-20-2024-22-AS-JTIE-D2N3SP-20240220173041

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005880
Report Date: 02/20/2024
Date Signed: 02/20/2024 05:30:47 PM

Document Has Been Signed on 02/20/2024 05:30 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:	SHORELINE SENIOR LIVING		FACILITY NUMBER:	306005880
ADMINISTRATOR:	EDGINGTON, HEATHER		FACILITY TYPE:	740
ADDRESS:	7101 NIMROD DR		TELEPHONE:	(714) 916-0029
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY:	6	CENSUS: 6	DATE:	02/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:05 PM
MET WITH:	Administrator Heather Edington		TIME COMPLETED:	05:45 PM

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On 2/20/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by caregiver and granted entry after stating the purpose of the visit. Administrator (AD) Heather Edington arrived immediately after.

The facility is licensed for six (6) non-ambulatory residents with approved hospice waiver for six (6) residents. Currently, there are four (4) Hospice residents present during today’s visit.

This is a single story with a two-car garage facility. The facility has five bedrooms (4 resident rooms & 1 staff room), and two full bathrooms.

At around 2:13 PM, LPA conducted a tour of the physical plant accompanied by Administrator Heather Edington, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. A comfortable temperature of 73 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has two fire extinguishers which fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. CONTINUED ON 809C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: SHORELINE SENIOR LIVING	FACILITY NUMBER: 306005880
	VISIT DATE: 02/20/2024

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LPA observed First Aid Kit was maintained. A working landline phone was operational at phone number 714-916-0029. The last fire drill was conducted on 12/15/23. The facility had operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 7/1/2023 - 7/1/2024. The facility is current on Community Care Licensing annual dues.

A review of three residents (R1-R3) service files and three staff (S1-S3) personnel files revealed to be complete. The facility has the current administrator's certification on file for Heather Edington # 6050352740 Expiration 05/23/2025.

No deficiencies during this inspection visit.

An exit interview was conducted with Caregiver Lady Manieda, and a copy of the report was provided

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC809 (FAS) - (06/04)

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