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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006070
Report Date: 11/01/2022
Date Signed: 11/01/2022 11:06:48 AM


Document Has Been Signed on 11/01/2022 11:06 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:COASTAL CHARM OF TUSTINFACILITY NUMBER:
306006070
ADMINISTRATOR:ALI, AHMADFACILITY TYPE:
740
ADDRESS:13341 ETON PLACETELEPHONE:
(949) 357-7633
CITY:NORTH TUSTINSTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 3DATE:
11/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Ali AhmadTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff and stated the purpose of this visit. Administrator Ahmad Ali arrived after the inspection.

The facility is a single level structure and licensed for six non-ambulatory with a hospice wavier for four. One may be bedridden. This facility offers Resident Care Facility for the Elderly.

At about 9:19 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed 3 residents in care and staff members on duty. LPA toured the interior and exterior portions of the facility. There were 5 resident rooms, 2 rooms were vacant. Facility offers a staff room which is inaccessible to residents. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide alarms were tested to be operational. Not all auditory exit alarms were working. Administrator was made aware of this and will replace auditory exit alarms. Bathrooms were observed to be in good repair and hot water was measured at 118.7 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. Kitchen was in good repair with cleaning supplies and sharps inaccessible to residents in care. Medications and toxins were locked and kept away from residents. Facility offers a 2-car garage mainly used for storage with a refrigerator for staff and residents and an operational washer and dryer.

For the exterior portion, facility had outside furniture in good repair; and grounds were free of tripping hazards. LPA was made aware of construction happening in the backyard. Gardening tools and equipment was made inaccessible to residents in care. LPA noticed that gates in the backyard were not self-latching. Administrator was made aware and will fix them.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
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 4


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: COASTAL CHARM OF TUSTIN
FACILITY NUMBER: 306006070
VISIT DATE: 11/01/2022
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LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency Disaster Plan of the facility. Administrator was informed of upcoming annual fees due in December. Administrator paid annual fees and was provided with a confirmation number.

LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for resident or resident use.

For this visit, no deficiency was noted in areas observed. Two advisories were issued.

LPA Tapia conducted an exit interview with Administrator Ahmed Ali and a copy of this report was explained and left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4