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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 312700808
Report Date: 08/11/2020
Date Signed: 08/11/2020 12:44:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:PACIFIC COAST CARE HOMESFACILITY NUMBER:
312700808
ADMINISTRATOR:ZAIDI, MARIAFACILITY TYPE:
740
ADDRESS:4470 ROLLING OAKS DRIVETELEPHONE:
(916) 823-3902
CITY:GRANITE BAYSTATE: CAZIP CODE:
95746
CAPACITY:6CENSUS: 0DATE:
08/11/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Maria Zaidi (Administrator)TIME COMPLETED:
12:45 PM
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Licensing Program Analysts (LPA) Konnor Leitzell and LPA Sabrina Calzada conducted a scheduled pre-licensing inspection via tele-visit on 8/11/2020. Due to COVID-19 and precautionary measures, this inspection was done over Google Duo. This is not a change in ownership and no residents were seen at the facility at this time.

LPAs and Administrator toured the interior and exterior of the facility, viewing the common areas, residents bedrooms, bathroom, kitchen, garage, and laundry. LPAs observed the facility to be clean, in good repair and to have sufficient furniture in common areas, both interior and exterior. LPAs observed sufficient lighting throughout the facility, and had wall lights for night time from residents rooms to the central bathrooms. LPAs viewed the outside gate was unlocked and the patio had a gazebo and ceiling fan for shade and comfort. LPAs viewed the thermometer for the running water at 106.4 degrees, and the refrigerator reading 34 degrees and the freezer reading 0 degrees. Facility had a 7+ day supply of non-perishables and an alarm sounding for when exterior doors are opened and closed. When viewing the living room, many activities were seen available. Administrator stated more personalized activities will be provided to residents when known. LPA's saw the fire alarms and Co2 detectors were in working condition by the administrator testing them. LPA's viewed the fire extinguisher was last serviced on March 3, 2020. When touring the kitchen and laundry room, administrator showed LPAs the locked cabinets for the sharps, detergents. LPAs checked and ensured the facility had sufficient dishes, flatware, cooking pans, and linens. LPAs viewed a complete first aid kit. LPAs viewed a locked medications room where staff files, resident files, and residents medications. There is currently a working land line in the facility that was viewed by LPA.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020
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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: PACIFIC COAST CARE HOMES
FACILITY NUMBER: 312700808
VISIT DATE: 08/11/2020
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LPAs observed the following posted at the facility: Resident Personal Rights, Rights of Resident/Family Councils, See Something Say Something, the Facility Sketch with evacuation routes, and the non-discrimination clause. Administrator told LPAs the Ombudsman poster will be posted once they receive it from the Ombudsman.

Facility did not have grab bars at the toilets, but did have in shower along with non-skid floor mats. LPA Leitzell requested to have the licensee email proof of purchase prior to being approved for license.

Comp III was conducted during today's inspection. ** Also, COVID-19 staff and resident precautionary measures were also discussed and resources materials were emailed following today's tele-visit. **

Pre-Licensing is incomplete with the following deficiencies to be resolved by 8/12/2020. A follow up will be generated upon resolution of deficiencies.
  • Proof of purchasing grab bars for toilets


LPA Leitzell is to notify the analyst in the application unit of inspection being completed and follow-up documentation needed.

An exit interview was conducted with Maria Zaidi, Administrator during today's tele-visit, and a copy of this report will be provided to the facility via email (sent 8/11/2020 at approximately 12:45 PM.) Two copies will be sent to the facility, 1 is to be signed and returned same day to CCL, and the other copy is to remain at the facility.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Konnor LeitzellTELEPHONE: (916) 708-9618
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2020
LIC809 (FAS) - (06/04)
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