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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006241
Report Date: 11/18/2022
Date Signed: 11/18/2022 03:35:49 PM


Document Has Been Signed on 11/18/2022 03:35 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:BEACHSIDE SENIOR CARE HOMEFACILITY NUMBER:
306006241
ADMINISTRATOR:BULLER, KATHRINAFACILITY TYPE:
740
ADDRESS:8011 SAIL CIRCLETELEPHONE:
(714) 274-9754
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 5DATE:
11/18/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Administrator, Kathrina BullerTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation. Facility is a single story residential home. LPA along with Administrator Kathrina Buller toured facility.

Fire clearance approval was received on 10/10/22. Structure: Facility is a one story, 7 bedroom (6 Residents bedrooms and 1 staff bedroom) 3 bathroom house with attached garage and a white exterior. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms meet Licensing requirements and have required furnishings such as Bed, night stand, drawer, chair, lamps and calling systems. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Facility has supply of linens and towels. Emergency Phone Numbers and Exit Plan: Facility has Emergency Disater Plan posted on wall. Food Service: Facility has 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, as well as emergency food and water supply. Facility has two fridges. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Fire extinguisher is mounted and charged. Facility has 2 extinguishers. Facility has audible alarms on all entrance/exit doors. Appliances: Gas Stove and refrigerators are operational. Toxins: LPA observed toxins secured in laundry storage area.. Water Temperature: Tested and recorded 113.1 degrees Fahrenheit in facility bathrooms. Reading Material Games, and Equipment:
facility does bingo, crossword puzzles and pet therapy. Medications, First-Aid Kit & Book: Facility has first aid kit present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with a self latching gate on one side of facility as required. LPA observed shaded outdoor seating.

CONTINUED ON 809C
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
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: BEACHSIDE SENIOR CARE HOME
FACILITY NUMBER: 306006241
VISIT DATE: 11/18/2022
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Component III Orientation was completed.

Facility has Publication 475 Posted however Administrator was advised to enlarge poster to 20x26 size. Administrator to provide proof of change to LPA.

No deficiencies noted during todays visit. The pre-licensing visit has been completed. This location is ready for licensure.


An exit interview was conducted with Administrator and a copy of report was left at facility
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
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