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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607898
Report Date: 08/30/2022
Date Signed: 08/30/2022 12:15:57 PM

Document Has Been Signed on 08/30/2022 12:15 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:COASTAL HOUSE, INC.FACILITY NUMBER:
197607898
ADMINISTRATOR:CLAUDIA PRECIADOFACILITY TYPE:
740
ADDRESS:2527 S. BUNDY DRIVETELEPHONE:
(310) 770-2029
CITY:LOS ANGELESSTATE: CAZIP CODE:
90064
CAPACITY: 6CENSUS: 4DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Caregiver -Cuthburt MartinezTIME COMPLETED:
12:30 PM
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On 08/30/2022, Licensing Program Analyst (LPA) Don Senaha conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA was met by caregiver Cuthburt Martinez and explained the purpose of today’s visit. The facility is licensed to serve six (6) elderly residents ages 60 and above of which five (5) can be non-ambulatory. The facility has a hospice waiver for five (5) residents.

The facility is a single-story structure located in a residential neighborhood. It consists of the following: four (4) resident rooms, two and a half (2.5) bathrooms, living area, dining area, kitchen, a detached office area in the backyard, a detached locked storage area and an outside shaded patio area with an umbrella and ample seating. All four (4) residents were in the facility at the time of the visit of which one (1) resident is receiving hospice care.

LPA and caregiver Cuthburt Martinez toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were operational. The water temperature met Title 22 regulations and measured between 108.0 F and 113.4 F in the bathrooms and kitchen sink.

There is driveway leading up to the house and the side of the house has a locked storage area for tools and supplies. The second storage area has extra sanitary supplies, PPE, emergency food, canned goods and an extra refrigerator/freezer for food storage. The washer and dryer is located in kitchen area.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2022
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: COASTAL HOUSE, INC.
FACILITY NUMBER: 197607898
VISIT DATE: 08/30/2022
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LPA observed the facility to be appropriately furnished at the time of visit. LPA observed cleaning supplies and toxins under the kitchen sink in a locked cabinet. The kitchen was inspected and there is sufficient perishable and non-perishable food available and properly maintained. There are two (2) fire extinguishers fully charged with one in the living room area and the other in the kitchen area. Smoke detectors and carbon monoxide were tested and operational. A review of Medication Administration Records (MAR) was maintained in order and accurate. There was a first aid kit available stored in the kitchen.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed all mandated inspection control posters were posted.

Advisory Notes – There was one (1) technical advisories issued. See LIC9102TA.

There no deficiencies cited during this inspection visit.

An exit interview was conducted with caregiver Cuthburt Martinez and Administrator Claudia Preciado on the phone and a copy of this report was provided to caregiver Cuthburt Martinez.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC809 (FAS) - (06/04)
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