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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320059
Report Date: 02/17/2022
Date Signed: 03/08/2022 03:28:45 PM

Document Has Been Signed on 03/08/2022 03:28 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:OCEAN BREEZE CARE HOME IIFACILITY NUMBER:
198320059
ADMINISTRATOR:MACELLUEN, GREGGFACILITY TYPE:
740
ADDRESS:26509 ROLLING VISTA DRTELEPHONE:
(310) 721-9667
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 6CENSUS: 4DATE:
02/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Gregg MacElluen, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Ana Soto conducted an unannounced Annual required and infection control visit to the above facility. LPA was met by Gregg MacElluen, administrator and the purpose of today’s visit was explained.

There are currently (4) residents in the facility. (4) residents are ambulatory and (0) are non-ambulatory. The facility is a single story structure located in a residential neighborhood. It consists (6) bedrooms, (3) full bathrooms - 2 for residents and 1 for staff, shaded back yard, front yard, laundry room and attached 2 car garage.

LPA and Gregg toured the entire facility inside and out. Documents are posted as mandated. Bedrooms 1-4 are occupied by residents and contain the mandated furniture. Bedroom 5 & 6 vacant but contain the mandated furniture. The (2) bathrooms are clean and operational. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are stored at facility and there's a water fountain in the back yard does not pose a hazard to residents. Medications are stored, locked and inaccessible to residents. Residents Medications and file are current. Staff file is current. Ample supply of perishable and nonperishable food, hot water temperature is 114 degrees Fahrenheit, linens and personal hygiene supplies are adequate, hazardous toxins and/or sharp items are inaccessible to residents, 1 fire extinguisher is fully charged. Exit, walkways and/or passageways, front and back yard are free of debris and/or hazards. The facility is in good repair. During the visit, LPA observed the facility infection control practices. LPA observed a sanitizing station at the facility entry, visitors are logged and temperature checked, sanitizer/soap in the bathrooms and additional sanitation supplies are locked in the garage. LPA observed staff and residents wearing masks, resident private rooms will be converted to isolation rooms (if needed) and required postings throughout the facility. The residents temperature's are checked and logged once a day. PPE's are enough for 30 days.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe any deficiencies, therefore no citations were issued at this time.

An exit interview conducted with Gregg MacElluen, Administrator and copy of report provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE: DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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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