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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602819
Report Date: 06/22/2023
Date Signed: 06/22/2023 10:40:26 AM

Document Has Been Signed on 06/22/2023 10:40 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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:COASTLINE ADULT RESIDENTIAL FACILITIES, INC.FACILITY NUMBER:
374602819
ADMINISTRATOR:ANDREW VAROSFACILITY TYPE:
735
ADDRESS:3517 SEA RIDGE ROADTELEPHONE:
(760) 722-7338
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY: 4CENSUS: 4DATE:
06/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Assistant Administrator Alberto Laureano TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Alyssa Ramirez conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified themselves to, and discussed the purpose of the visit with assistant administrator Alberto Laureano. According to the facility’s license, the facility has a maximum capacity of four (4) clients, of which one (1) may be non-ambulatory. There was a total of four (4) client in care, per physician’s report’s one (1) client is non-ambulatory and three (3) are ambulatory.

LPA, accompanied by assistant administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 109 F and bathroom #1 sink was 112 F.

There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.




[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/22/2023
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
SO. CAL AC/SC, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: COASTLINE ADULT RESIDENTIAL FACILITIES, INC.
FACILITY NUMBER: 374602819
VISIT DATE: 06/22/2023
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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. Per assistant administrator, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed assistant administrator and reviewed multiple staff and client records/files. LPA interview did not raise any licensing concerns. LPA was unable to interview staff and clients due to them being at day program when inspection was conducted. The files which LPA reviewed contained all required documents. Confidential records were stored in locked area.

No deficiencies were cited during today's annual inspection.

An exit interview was conducted with Laureano to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Alyssa Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023
LIC809 (FAS) - (06/04)
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