306005901-6-7-2022-22-AS-SFRK-CF74T5-20220607192235

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005901
Report Date: 06/07/2022
Date Signed: 06/07/2022 07:23:21 PM

Document Has Been Signed on 06/07/2022 07:23 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:	BEACH TERRACE MEMORY CARE		FACILITY NUMBER:	306005901
ADMINISTRATOR:	EDWARDS, CYNTHIA		FACILITY TYPE:	740
ADDRESS:	12282 BEACH BOULEVARD		TELEPHONE:	(503) 675-3925
CITY:	STANTON	STATE: CA	ZIP CODE:	90680
CAPACITY:	120	CENSUS: 0	DATE:	06/07/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Owners representative Mark Gottschlich.		TIME COMPLETED:	02:03 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 Analysts (LPA) Shobhana Frank conducted an announced visit for the purpose of a Pre-Licensing inspection and COMP III. LPA Frank was greeted and granted entry to the facility by Owners representative Mark Gottschlich. An initial application to operate a Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 3/16/2022 for a capacity of 110 Non-ambulatory residents. LPA Frank toured the facility along with Chief Operating Officer Lance Leland and Operation & Marketing Specialist Eric Jansen. During today's inspection, LPA observed the following: This facility is residential Care for the Elderly (Memory Care). The facility is three story building, the first floor is offices and kitchen, second floor has 33 apartments with the large outdoor Deck, third floor has 33 apartments, total capacity 110. Facility offers a beauty salon, activity area several dining areas as well as outside patio areas. Living Room/ Dining Room: Adequate seating is available in the main dining room and activity areas. All apartments are equipped with appropriate lighting, chair, night stand and ample closet space. All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. LPA Frank observed emergency Phone Numbers and Exit Plan Posted in entrance of facility. Facility has ample of perishable and non perishable food supplies. The water temperature was measured 106 Fahrenheit degrees in 4 residents bathrooms. LPA observed a posted menu with multiple choices for residents. Fire extinguishers were mounted and charged. Smoke detectors were centrally wired throughout and have been checked by the fire department. The facility has dual smoke detectors and carbon monoxide detectors throughout the building. There were two locked medication rooms on the second and third floor. Both medication rooms store first aid kits. There is a large storage of toxins and cleaning equipment in the kitchen area, An emergency call system was in place in each apartment unit, each apartment units has heater and air-condition. A fire clearance was granted on 5/12/22.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022

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: BEACH TERRACE MEMORY CARE	FACILITY NUMBER: 306005901
	VISIT DATE: 06/07/2022

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The kitchen area was checked. All equipment were in working condition. LPA observed activity calendars, theft and loss policy, admission agreement, resident rights and emergency plans were posted, including the Ombudsman and Let Us Know poster.
Component III was conducted with, Chief Operating Officer Lance Leland and Operation & Marketing Specialist Eric Jansen.

It appears that this facility meets the requirements for licensure.
Licensure was informed today that the facility is ready for licensure and final approval will be processed by the CAU supervisor in Sacramento. An exit interview was conducted with Licensure and copy of report was provided.

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Shobhana Frank	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022

LIC809 (FAS) - (06/04)

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