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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320059
Report Date: 02/16/2023
Date Signed: 02/16/2023 01:04:49 PM

Document Has Been Signed on 02/16/2023 01:04 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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:OCEAN BREEZE CARE HOME IIFACILITY NUMBER:
198320059
ADMINISTRATOR:MACELLVEN, GREGFACILITY TYPE:
740
ADDRESS:26509 ROLLING VISTA DRTELEPHONE:
(310) 721-9667
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY: 6CENSUS: 5DATE:
02/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:43 AM
MET WITH:Gregg MacEllven-Owner/AdministratorTIME COMPLETED:
01:03 PM
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On 2/16/23 Licensing Program Analyst Alfonso Iniguez conducted an unannounced visit to this facility. The purpose of today’s visit was to conduct an Annual inspection. LPA met with Gregg MacEllven/Owner-Administrator. Facility is licensed for (6) non-ambulatory residents. The facility has an approved hospice waiver for (2) residents. The facility currently has (5) non-ambulatory residents, who are residing in the facility. The facility does not handle residents’ cash resources.

LPA toured the facility. The facility consists of (6) resident bedrooms, (3) bathrooms, living room, dining room and kitchen. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Bathrooms are clean, sanitary, and fixtures are working properly, the bathrooms grab bars are secure and non-skid mats in place. The facility water temperature properly measured at 111 F°. Resident bath towels, toiletries, and personal hygiene supplies were adequately stocked. Common areas were clean and hazard free. All doorways were free of obstructions and have auditory alarm.

The kitchen is clean, sanitary, and observed to be within Title 22 regulations. The facility currently has a sufficient supply of perishable as well non-perishable food items. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors and Carbon monoxide detectors were tested and found to be operating properly. Outside grounds were toured and no bodies of water were observed. All walkways around the home were clear of hazards. The front porch and the back patio have shaded and sitting areas for residents and visitors.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: OCEAN BREEZE CARE HOME II
FACILITY NUMBER: 198320059
VISIT DATE: 02/16/2023
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LPA observed a sign-in/sanitation station at the facility entry. There is hand sanitizer and masks available in the facility. Facility has screening process for all visitors, sanitizer/soap, paper towels, and additional PPE supplies are stored inside the facility and garage. The facility is prepared to provide a private room for isolation if needed. The facility mitigation plan was approved by CCL on 5/23/2021.

A copy of the liability insurance was provided to LPA.


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

An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to the Owner/Administrator Gregg McEllven .
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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