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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602819
Report Date: 08/22/2024
Date Signed: 08/22/2024 12:48:11 PM

Document Has Been Signed on 08/22/2024 12:48 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:COASTLINE ADULT RESIDENTIAL FACILITIES, INC.FACILITY NUMBER:
374602819
ADMINISTRATOR/
DIRECTOR:		ANDREW VAROSFACILITY TYPE:
735
ADDRESS:3517 SEA RIDGE ROADTELEPHONE:
(760) 722-7338
CITY:OCEANSIDESTATE: CAZIP CODE:
92054
CAPACITY: 4CENSUS: 3DATE:
08/22/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Assistant Administrator Alberto LaureanoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management visit. The LPA introduced himself to and disclosed the purpose of the visit to Assistant Administrator Alberto Laureano.

On 8/21/2024, the Department received an Incident Report reporting Client # 1’s (C1) death. During the visit the LPA conducted a tour of the facility, collected pertinent records for C1, and conducted an interview. There were no immediate health, nor safety concerns observed, and no deficiencies were cited during the visit. Submission of a death certificate was requested, once it became available to the facility.

An exit interview was conducted with Laureano, to whom a copy of this report, LIC 811 Confidential names list, and Licensee Rights (LIC 9058), were provided.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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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