374604625-2-22-2023-08-AS-DNGN-CPAS5J-20230222123426

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604625
Report Date: 02/22/2023
Date Signed: 02/22/2023 12:34:35 PM

Document Has Been Signed on 02/22/2023 12:34 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:	CORONADO SENIOR LIVING INC		FACILITY NUMBER:	374604625
ADMINISTRATOR:	MANASYAN, LINET		FACILITY TYPE:	740
ADDRESS:	930 COUNTRY LN		TELEPHONE:	(818) 858-7543
CITY:	CORONADO	STATE: CA	ZIP CODE:	92118
CAPACITY:	6	CENSUS: 0	DATE:	02/22/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Applicants Linet Manasyan and Anna Petrosyan		TIME COMPLETED:	12:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Dang Nguyen conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to applicants Linet Manasyan and Anna Petrosyan. The facility fire clearance was granted on January 9th, 2023 and reflects that the facility is approved for six (6) residents in total, of which four (4) may be non-ambulatory and one (1) may be bedridden. During today’s visit, LPA, accompanied by the applicants, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets and showers were in working order. The facility’s ambient internal temperature was 74 F. Water temperature at taps accessible to residents were also compliant: Kitchen was 113.7 F, Bathroom #1 was 114.6 F, Bathroom #2 was 113.4 F, and Bathroom #3 was 118.9 F. The facility has enough linens, hygiene supplies, dining supplies, and perishable and non-perishable food for future resident use. Refrigerator temperature was 39 F, and freezer temperature was 0 F. The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of medication and confidential resident and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant, no firearms or ammunition are or will be stored at the facility. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: CORONADO SENIOR LIVING INC	FACILITY NUMBER: 374604625
	VISIT DATE: 02/22/2023

NARRATIVE

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[CONTINUED FROM LIC 809]

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. Two (2) fire extinguishers and one (1) first aid kit were present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6 of California Code of Regulations and Health & Safety Code. The applicants passed the pre-licensing inspection. LPA also provided the Component III Training during today’s visit. The applicants were advised that the facility’s application is pending management final review and approval. An exit interview was conducted with Manasyan, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023

LIC809 (FAS) - (06/04)

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