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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006876
Report Date: 05/28/2026
Date Signed: 05/28/2026 04:09:39 PM

Document Has Been Signed on 05/28/2026 04:09 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:BEACHSIDE SENIOR CARE HOME 2FACILITY NUMBER:
306006876
ADMINISTRATOR/
DIRECTOR:		BULLER, KATHRINAFACILITY TYPE:
740
ADDRESS:17341 GIBSON CIRCLETELEPHONE:
(714) 749-6629
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6CENSUS: 0DATE:
05/28/2026
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Kathrina BullerTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Nancy Guillen conducted an announced visit to the facility for purpose of a pre-licensing evaluation. An initial application to operate a Residential Care Elderly Facility for six non-ambulatory residents of which one may be bedridden was submitted to CCL on November 7, 2025.


LPA met with applicant Kathrina Buller. LPA observed that Administrator Kathrina Buller has a valid Administrator certificate which expires on October 30, 2026. Administrator was background cleared and associated to the facility. The facility received an approved Fire Clearance by Orange County Fire Authority Inspector Christopher Bird on December 10, 2025.

The facility is a two -story home with five resident bedrooms, three bathrooms, a kitchen, a dining room, a living room, backyard and attached garage with an exterior entry. LPA accompanied by the applicant, conducted a tour of the physical plant. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall in the entryway of the facility. LPA inspected the five resident bedrooms. The five bedrooms are clean and free of hazards. LPA observed all the resident bedrooms has the required furnishings of a bed, a chair, and chest of drawers, and a lamp. Resident beds have clean linens and blankets. LPA observed additional linens stored in a cabinet in bathroom #1. Client bathrooms are clean. Bathrooms were equipped with grab bars and non-slip mats. Faucets and toilets were operational. Hot water temperature measured between 110.6 and 112.2 degrees Fahrenheit. LPA observed the facility has an emergency food and water supply and personal protective equipment stored in a hallway cabinet.

Continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/28/2026
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 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: BEACHSIDE SENIOR CARE HOME 2
FACILITY NUMBER: 306006876
VISIT DATE: 05/28/2026
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LPA observed the facility has board games, books, and other recreational materials for the residents use stored in the living room. The facility has two internet devices for resident use. Resident and staff records are in a shelf in the hallways accessible to residents. LPA advised applicant to place files in a locked area inaccessible to residents or public.

LPA observed the kitchen has a minimum two-day perishable and seven-day non-perishable food supply. LPA observed the kitchen to be clean and free of vermin. LPA observed the gas stove, refrigerator, microwave, washer, dryer and dishwasher were all observed to be clean and operational. LPA observed knives to be locked underneath the kitchen sink. Fire extinguishers are located in the dining room and stairway. Fire extinguishers were observed to be charged and serviced as of December 5, 2025. LPA observe the smoke and carbon monoxide detectors were operational. Auditory devices tested operational for all exits. The centrally stored medication is located in a locked hallway cabinet. LPA observed the First Aid Kit had all the required components. The garage is inaccessible to residents and is used as an office space and storage, however the office room is not reflected on the facility sketch and the measurements of the garage are incorrect. LPA informed applicant that the facility sketch must accurately represent the current rooms and their designated uses. Applicant stated a new fire clearance will be conducted. Cleaning supplies are located in hallway closet in between bedroom #5 and the stairs .

LPA accompanied by the applicant toured the outside of the facility and observed it to be free of obstructions and hazards. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter gate on the exterior of the facility is self-latching and can easily be opened in an evacuation. There are no bodies of water on the premises. LPA informed applicant evacuation is required due to two-story home. Applicant stated they will purchase an evacuation chair.

LPA informed applicant that the corrections and repairs need to be made before approval from the Centralized Application Bureau can be made. Applicant will notify LPA when the corrections and repairs are completed and schedule another pre-licensing visit with LPA.

An exit interview was conducted and a copy of this report was left at the facility.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC809 (FAS) - (06/04)
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