306006466-5-9-2024-22-AS-JCHO-D54P3S-20240509105800

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006466
Report Date: 05/09/2024
Date Signed: 05/09/2024 10:58:15 AM

Document Has Been Signed on 05/09/2024 10:58 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	PACIFIC COAST MENTAL HEALTH		FACILITY NUMBER:	306006466
ADMINISTRATOR/ DIRECTOR:	CISNA, DEREK		FACILITY TYPE:	772
ADDRESS:	2798 WAXWING CIRCLE		TELEPHONE:	(949) 480-7126
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY: 6		CENSUS: 0	DATE:	05/09/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Dr. Soren Shamisian- Program Director Christina Farschain- Vice President of Operations, Laura Hagan, Compliance Manager Shayla Linn- Operations Manager		TIME VISIT/ INSPECTION COMPLETED:	11:15 AM

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Licensing Program Analysts (LPAs) Jessica Cho and Rose Ruppert conducted an announced Pre-Licensing visit with Component III Orientation at Pacific Coast Mental Health. LPAs conducted the visit with Dr. Soren Shamsian, Program Director, Christina Farschian, Vice President of Operations, Laura Hagan, Compliance Manager and Shayla Linn, Operations Manager. An initial application to operate a Social Rehabilitation Facility was submitted to the Central Applications Bureau (CAB) on October 30, 2023 for a capacity of six ambulatory clients.

LPAs toured the interior and exterior of the facility and observed the following:

Structure:

Facility is a one story building with three shared client bedrooms, two bathrooms, living room which doubles as a group room, two offices, dining room, kitchen, laundry, and an attached three car garage. There is a front yard with a grass area and a backyard with two smoking areas and shaded seating areas.

Signal System:
The facility does not have a signal system. The thermostat is located in the hallway.

Bedrooms :
All three bedrooms accommodate ambulatory clients with two clients per bedroom. The client bedrooms accommodate their furnishings.

Bathrooms:
All bathrooms have a working toilet, wash basin, and showers. Grab bars were secure.
[Continued on LIC809-C....]

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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: PACIFIC COAST MENTAL HEALTH	FACILITY NUMBER: 306006466
	VISIT DATE: 05/09/2024

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Linens and Hygiene Supplies:
Adequate supply of linens were located in a locked cabinet in the garage. The hygiene supplies were also be locked and stored in the garage.
Appliances: Refrigerator, freezer, dishwasher, washer and dryer, six burner gas stove top, microwave, and an oven were in working condition.
Emergency Phone Numbers/Exit Plan:
Posted in the entry area of the facility and readily available for review.
Postings:
The Complaint Poster (PUB475) was posted in the entry area of the facility.
Food Service and Menu:
There was an adequate supply of seven day non-perishable and two day perishables will be provided when clients are present in the facility. The sample menu was available for review. The emergency food/water supply was present in garage.
Smoke and Carbon Monoxide Detectors:
Smoke detector and carbon monoxide alert systems were interconnected, tested, and found to be operational.
Fire Extinguishers:
Five fire extinguishers were fully charged and serviced on December 23, 2023 .One extinguisher will be in the company vehicle.
Fire Clearance:
Approved on January 12, 2024 for six ambulatory clients.
Toxins and Sharps:
The cleaning supplies were locked and stored in a garage cabinet. The knives and other sharp items were also stored in a locked garage cabinet.
Water Temperature:
Tested and recorded in two client bathrooms. Bathrooms #1 and #2 measured at 109.5 degrees Fahrenheit.
Medications, First Aid Kit & Manual:
The facility had several First Aid Kits which were checked and found to be in order. The First Aid kit is located in both offices and garage and will be locked. The facility has a First Aid manual.

[Continued on LIC809-C....]

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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: PACIFIC COAST MENTAL HEALTH	FACILITY NUMBER: 306006466
	VISIT DATE: 05/09/2024

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Client and Staff Files: Client and staff records will be stored in the office.

Reading Material, Games, Equipment, & Materials:
The facility had reading material and games present in the facility that commensurate with their plan of operation.

Component III:
Conducted at the Pre-Licensing visit- information was provided about how to operate the facility within compliance.

The items reviewed during this visit are in compliance. The Pre-Licensing is complete and the facility appears ready for licensure. The license will be granted upon completion of a final review and approval from the Licensing Program Manager and the Central Applications Bureau. Facility representatives, Dr. Soren Shamsian, Christina Farschian, Laura Hagan, and Shayla Linn were reminded of the statute that requires them to notify the Department within five business days of admitting the first client. This notification may be done by phone, mail or fax.

An exit interview was conducted with Program Director Dr. Soren Shamsian, Vice President of Operations Christina Farschian, Finance Manager Laura Hagan, and Operations Manager Shayla Linn, and a copy of this report was provided at the end of the visit.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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