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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005951
Report Date: 04/11/2024
Date Signed: 04/12/2024 06:25:09 AM


Document Has Been Signed on 04/12/2024 06:25 AM - 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: 5DATE:
04/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Michelle BurtonTIME COMPLETED:
01:05 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and Michael Tea conducted an unannounced visit to Ocean Breeze Living. The purpose of today’s visit was to conduct the Annual Required inspection. LPAs were allowed entry into the home and met with Caregiver Michelle Burton. Facility is licensed for 6 non-ambulatory residents, one of which may be bedridden. Facility has an approved hospice waiver for 2 residents and the home currently has 5 residents. There is 1 resident on hospice during today's visit. Kelly Anderson has an Administrator Certificate expiring on 02/24/2025.

LPAs Lyman and Tea along with Administrator toured the facility at 9:35 AM. LPAs toured the physical plant, checked food service, and the first aid kit. Facility appears to be clean, safe, and sanitary. The home consists of five resident bedrooms, two shared hall bathrooms, living room, dining room, and kitchen on the first floor and three bedrooms and a bathroom on the second floor. There are no residents residing on the second floor. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. LPAs observed three residents with a half bed rails. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 108.5 and 109 degrees F in all facility bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. First aid kit had all the required elements including tweezers, thermometer, and scissors. During today's visit, auditory door alarms are operational. The entry door into the garage is secured. LPAs observed a locked storage area for cleaning supplies under the kitchen sink. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPAs observed sharps locked in a kitchen drawer. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPAs toured the outside grounds and there is ample shaded seating for residents. Exit gates are unlocked. LPAs observed emergency food and water supply in the garage. LPAs reviewed the emergency disaster plan during the visit. Plan is thorough and complete. CONTINUED ON LIC 9099C DATED 04/11/2024

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 04/11/2024
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Facility provides activities in the form of games, exercise, and music therapy. At 10:30 AM, LPAs reviewed five resident files and three staff files. Resident files contained required documents including admission agreements, current physician reports, resident appraisals and physician orders for bed rails as indicated.. Staff files reviewed contained required documentation of annual training, health screen/TB, and criminal record clearance. At 11:30 AM, LPAs reviewed medication storage and administration. Medications are stored in a locked cabinet and are audited monthly by staff. Medications are being administered per physician order.

Based on the observations made during today's visit, no deficiencies are being cited.
Exit interview conducted and a copy of this report was given at time of visit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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