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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005951
Report Date: 04/04/2022
Date Signed: 04/04/2022 04:10:31 PM


Document Has Been Signed on 04/04/2022 04:10 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:OCEAN BREEZE LIVING LLCFACILITY NUMBER:
306005951
ADMINISTRATOR:ANDERSON, KELLYFACILITY TYPE:
740
ADDRESS:5332 LUDLOW AVETELEPHONE:
(562) 355-5544
CITY:GARDEN GROVESTATE: CAZIP CODE:
92845
CAPACITY:6CENSUS: 4DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cherry Mayor and Kelly AndersonTIME COMPLETED:
11:40 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Kimberly Lyman and Claudia Gutierrez conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility and explained the reason for the visit. Administrator Kelly Anderson arrived during the visit. Kelly Anderson has an administrator certificate expiring on 2/24/23.

At 9:50 AM, LPAs toured the facility with Administrator Kelly Anderson. Facility has 4 residents in care during today's visit with 1 resident on hospice care. LPAs observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements. Facility screens all visitors to the facility and LPAs observed the screening/ sanitizing station in the facility. Facility utilizes a hand written visitor sign in sheet. Facility takes resident and staff temperatures daily and documents. LPAs observed the first aid kit has all required items. Smoke detectors tested operational during today's visit. LPAs observed sufficient supply of emergency food and water as well as emergency supplies. LPAs observed multiple shaded outside visitation areas. Exit gate was unlocked. LPAs observed the locked medication area. Facility utilizes a medication administration record. Facility provides activities in the form of exercise and social hour. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPAs reviewed all resident files during the visit and all files have updated emergency information as well as required documents. All residents and staff are vaccinated for Covid-19.

Licensee to forward a copy of the mitigation plan to LPA Lyman by 04/11/2022.

No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
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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