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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602481
Report Date: 01/23/2024
Date Signed: 01/23/2024 04:07:31 PM

Document Has Been Signed on 01/23/2024 04:07 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:
01/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Administrator Alberto LaureanoTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Administrator Alberto Laureano.

This visit was initiated due to an incident report that was self reported by the Licensee to the Department on 1/17/2024. The incident report narrative described that Client 1 (C1) had a behavior and fell. [Administrator was provided with LIC811 Confidential Names List to identify C1] The following day, C1 was transported to the hospital where C1 was diagnosed with an injury.

During today’s visit, LPA toured the facility, conducted a health and safety check, and reviewed and obtained copies of facility records. Clients were not present at the facility during the time of the visit. No immediate health or safety concerns were observed during the facility tour.

No deficiencies were cited during today’s visit. An exit interview was conducted with Administrator Alberto Laureano, whose signature below confirms receipt of a copy of this report, LIC811, and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2024
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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