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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602481
Report Date: 05/26/2022
Date Signed: 05/26/2022 06:14:37 PM

Document Has Been Signed on 05/26/2022 06:14 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:COASTLINE ARF INC. PALO VERDEFACILITY NUMBER:
374602481
ADMINISTRATOR:LAUREANO, ALBERTOFACILITY TYPE:
735
ADDRESS:3702 PALO VERDE WAYTELEPHONE:
(760) 842-1480
CITY:OCEANSIDESTATE: CAZIP CODE:
92056
CAPACITY: 4CENSUS: 4DATE:
05/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:55 PM
MET WITH:Alberto LaureanoTIME COMPLETED:
06:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA identified herself to, was allowed entry by, and explained the purpose of the visit to Caregiver Eugina Bizzaro. Administrator Alberto Laureano arrived during the visit.

LPA conducted a tour of the facility and observed the clients in care. In accordance with the Department’s Infection Control, LPA provided technical assistance, observed, and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, testing, vaccination, screening protocols, and the use of personal protective equipment.

During the visit, it was revealed that Staff 1 (S1) has been working at the facility since 5/1/2020 and does not have a criminal background exemption on file for this facility [Administrator was provided with an LIC811 Confidential Names List to identify S1]. A civil penalty in the amount of $500 has been assessed during this visit.

This deficiency is noted on the attached LIC809-D page, and is cited in accordance with the California Code of Regulations, Title 22. An exit interview was conducted with Administrator Alberto Laureano, to whom a copy of this report and the licensee appeal rights (LIC9058 01/16) were provided via hard copy.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/26/2022
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 2
Document Has Been Signed on 05/26/2022 06:14 PM - It Cannot Be Edited


Created By: Rebecca A Ruiz On 05/26/2022 at 05:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: COASTLINE ARF INC. PALO VERDE
FACILITY NUMBER: 374602481

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied: Appeal Not Submitted Timely
Type A
Section Cited
CCR
80019(e)(3)
80019(e)(3) all individuals... shall prior to working, residing or volunteering in a licensed facility: request and be approved for a transfer of a criminal record exemption...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not request a criminal background exemption transfer for S1 which poses an immediate safety risk to 4 of 4 clients in care. A civil penalty of $500 has been assessed.
POC Due Date: 05/27/2022
Plan of Correction
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Administrator will submit paperwork to request the criminal background exemption transfer for S1. S1 left the facility prior to LPA concluding the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022


LIC809 (FAS) - (06/04)
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