198320360-6-2-2023-11-AS-ASOO-CSER3W-20230602124033

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198320360
Report Date: 06/02/2023
Date Signed: 06/02/2023 12:56:55 PM

Document Has Been Signed on 06/02/2023 12:56 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 III		FACILITY NUMBER:	198320360
ADMINISTRATOR:	MACELLVEN, GREGG		FACILITY TYPE:	740
ADDRESS:	1600 W 21ST		TELEPHONE:	(310) 721-9667
CITY:	SAN PEDRO	STATE: CA	ZIP CODE:	90732
CAPACITY: 6		CENSUS: 0	DATE:	06/02/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Gregg Macellven, Administrator		TIME COMPLETED:	12:30 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 Analysts (LPA) Ana Soto conducted an announced visit to the facility for the purpose of a Pre-Licensing evaluation. An application was submitted to Community Care Licensing Department (CCLD) on 12/06/2022 for an initial license for Residential Care For Elderly 60 years and above. The requested capacity is for (6) residents, (2) ambulatory and (4) non-ambulatory. Structure: Facility is a (7) bedroom, one (2) full bathroom, single story house with small front porch with small ramp, stairs on east side of facility, back covered porch with ramp, and attached 2 car garage. The facility is a orange stucco with wood structure and small backyard. Front yard landscape is in good condition. Rear patio is covered. and has table and chairs, washer/dryer area with wash basin. Signal System: Signal system in facility. Bedroom Residents: There shall be no more than two residents per bedrooms. 6 Bedrooms are designated private bedrooms properly equipped with regulation guidelines of one bed, one chair, one night stand, one lamps and overhead lighting. Bedroom Staff: One bedroom will be used for awake staff. Bathrooms: 1 full bathroom located in the east side of facility next to the kitchen and 2nd bathroom is located next to living room between bedroom #3 and bedroom #4, both have working toilets and wash basins. Bathrooms also contain grab bars, folding bench, and non-skid mats. Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen is stored in hallway closets, and bathroom cabinet. Emergency Phone Numbers, Exit Plan, & Menu: Emergency numbers and menu are posted and readily available for review in the north hallway. Facility has a land line telephone located in the office. 2 Fire extinguishers, one 4A60BC mounted in laundry area, and the second 4A60BC is next to the back door which is labeled, they are tagged with current annual checks.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: OCEAN BREEZE CARE HOME III	FACILITY NUMBER: 198320360
	VISIT DATE: 06/02/2023

NARRATIVE

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Food Service: Dishes, cups, and flatware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery, and other sharp kitchen utensils are stored in locked storage drawers in the kitchen cabinets. Adequate food supply is stored in kitchen, and consists of the following: 2 day perishables, and 7 week non-perishables. Smoke Detectors: There are 9 hard wired smoke detectors, and 1 battery operated carbon monoxide detector located in the living room are operational. Appliances: Stove, microwave, and washer/dryer, refrigerator are in working condition. There is second refrigerator in the garage. The residence is equipped with central heat and no air conditioning. Toxins: Cleaning supplies, and toxins are stored in one location: locked cabinet in the cabinet inside the laundry area. Water Temperature: Water was tested in bathrooms and kitchen sink within 106 degrees Fahrenheit. Medication, First-Aid Kit & Book: Designated area for centrally stored medication is located in the office with lock. A first-aid kit has been inspected which has at least the following: thermometer, tweezers ,scissors, antiseptic, bandages, gauze and current first aid manual, which is mounted in the wall above the fire extinguisher next to the back door, available for staff use. Resident & Staff Files: Designated area for files will be located in the office in a locked cabinet. Pools/Jacuzzi & Pets: No bodies of water and no pets on these premises. . Fire Clearance: Fire clearance does not indicate any delayed egress or any locked perimeter. Component III: Waived at the time of Pre-Licensing.

No corrections needed.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Unit (CAU) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAU Analyst assigned to their application.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ana Soto
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023

LIC809 (FAS) - (06/04)

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