306005951-3-30-2021-22-AS-KLYN-BZLTPC-20210330145404

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005951
Report Date: 03/30/2021
Date Signed: 03/30/2021 02:54:19 PM

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:	OCEAN BREEZE LIVING LLC		FACILITY NUMBER:	306005951
ADMINISTRATOR:	ANDERSON, KELLY		FACILITY TYPE:	740
ADDRESS:	5332 LUDLOW AVE		TELEPHONE:	(562) 355-5544
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92845
CAPACITY:	6	CENSUS:	DATE:	03/30/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Kelly Anderson and Scott Anderson		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) Kimberly Lyman made an announced pre-licensing visit. LPA identified herself and discussed the purpose of the visit with Licensee's Kelly and Scott Anderson. An initial application to operate a Residential Facility Care for the Elderly was received by CCL on 12/16/2020 for a capacity of 5 non-ambulatory residents and 1 bedridden resident. Administrator Kelly Anderson has an administrator certificate expiring on 02/24/2023. There are no residents in care during today's visit. LPA Lyman along with Licensee's Kelly and Scott Anderson toured the facility at 1:10 PM and observed the following: Structure: Facility is a two story, 8 bedroom, 3 bathroom house with an attached garage and a light yellow exterior. The exit gates are closed and unlocked. Resident living area is on the first floor and staff room is on second level. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Five bedrooms are single occupancy and one is double occupancy. All rooms are equipped with appropriate lighting, chair, night stand, ample closet space. All exit doors are equipped with working auditory exit alarms. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Linen supply is in ample supply for residents in care. Emergency Phone Numbers and Exit Plan: Licensee to post in the entrance area of the facility. Food Service: Facility has ample 2 day perishables as well as 7 day non-perishables in the pantry. LPA observed a sample menu. Smoke Detectors: Smoke detectors/ carbon monoxide detectors are centrally wired and were tested operational. Fire extinguishers are fully charged. Appliances: Stove, oven, refrigerator, microwave, washer, and dryer are clean and operational. Toxins: Stored in the garage. Licensee to obtain lock for kitchen toxins. Water Temperature: Tested and recorded between 105.8 and 107.4 degrees F.in facility bathrooms. Emergency Supplies: LPA observed ample emergency food and water stored in the garage. CONT ON LIC 809C DATED 03/30/2021.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

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: OCEAN BREEZE LIVING LLC	FACILITY NUMBER: 306005951
	VISIT DATE: 03/30/2021

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Medications, First-Aid Kit & Book: First aid kit observed contained all required items. LPA observed completed emergency disaster plan. Medication to be stored and locked in a locked closet in the entry of the facility. Facility uses a medication administration record. Resident & Staff File: Records to be locked in a closet in the hallway. Reading Material, Games, and Equipment: LPA observed games in the facility. Facility to post activity schedule once residents are admitted. Backyard: LPA observed a clean, safe backyard with ample shaded seating for residents. Fire Clearance: Approved for 5 non-ambulatory residents and 1 bedridden on 03/03/2021.

Licensee to address the following items:

Secure kitchen toxins
Obtain tweezers for first aid kit.
Place hand washing signs in facility restrooms.

The facility is ready to be licensed. As noted above, a Component III was conducted during this visit as well.

An exit interview was conducted with Licensees and a copy of this report.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2021

LIC809 (FAS) - (06/04)

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