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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006392
Report Date: 08/01/2024
Date Signed: 08/01/2024 03:32:54 PM


Document Has Been Signed on 08/01/2024 03:32 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:BEACH HOMES IIFACILITY NUMBER:
306006392
ADMINISTRATOR:N/AFACILITY TYPE:
740
ADDRESS:2572 COLUMBIA DRIVETELEPHONE:
(949) 302-0180
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY:6CENSUS: 5DATE:
08/01/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Andrew BeachTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Michael Tea made an announced visit to the facility for the purpose of conducting a pre-licensing inspection. LPA Tea met with designated Licensee (LE) Andrew Beach and prospective Administrator (AD) Samantha Chiascione.

An application to operate a Residential Care Facility for Elderly (RCFE) was received by our agency on October 20, 2023 for a total capacity of six; six non ambulatory and four may be on hospice. There are currently five residents residing in the facility, Beach Home II RCFE #306002908, that is to be transferred to AJB Investment Group Inc., doing business as Beach Homes II. Fire clearance was approved by a fire inspector from the Orange County Fire Authority on May 28, 2024.

The facility is a one-story home with seven resident bedrooms, seven bathrooms, a living room, a kitchen, a dining area, and an attached car garage. All exiting doors had alarm notifications. There are two backyard exit gates on each side of the house that is self-latching and unlocked. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard.

LPA observed Administrator certificates, See Something, Say Something poster (PUB 475), Personal Rights, Ombudsman poster, Facility sketch and Emergency Disaster Plan in the facility mounted on the wall around the facility kitchen. Fire extinguisher is in the kitchen fully charged with an inspection date of May 08, 2024.

Resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets. All toxic chemicals, cleaning solutions, and disinfectants are inaccessible to residents is stored and locked underneath the kitchen sink. Medications were stored in a locked cabinet in the kitche. The first aid kit is also stored in a locked cabinet in the kitchen and has all the required elements. Staff and resident records is stored and locked in a filing cabinet in the living room.

Pre-Licensing continuation on LIC809C

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: BEACH HOMES II
FACILITY NUMBER: 306006392
VISIT DATE: 08/01/2024
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Reading materials and games were observed in the dining room and living room. Phones are located in the dining room and living room for residents to use, as well as a laptop in the dining room.

A supply of seven-day of perishable and non-perishable food was observed. Smoke detectors and carbon monoxide detectors tested operational. Gas burner stove, dishwasher, refrigerator, microwave, washer, and dryer are operational. There are cameras placed in the common areas of the facility without audio for the safety of residents in care. Hot water temperatures in the bathrooms measured between 109 F degrees. Emergency food and water and additional supplies were observed to be well stocked in the garage.



The facility is ready to be licensed. LPA conducted the Component Three Orientation with LE and AD. Licensee was notified that the final application approval will be issued by the Centralized Applications Bureau in Sacramento. An exit interview was conducted, and a copy of this report was provided to the Licensee.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Michael TeaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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