306001961-7-21-2022-22-AS-JCHO-CGJS9Q-20220721134107

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001961
Report Date: 07/21/2022
Date Signed: 07/21/2022 01:41:35 PM

Document Has Been Signed on 07/21/2022 01:41 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	COASTSIDE SENIOR HOME		FACILITY NUMBER:	306001961
ADMINISTRATOR:	JOSELITO RIVERA		FACILITY TYPE:	740
ADDRESS:	3264 COLORADO LANE		TELEPHONE:	(714) 444-9800
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY: 6		CENSUS: 3	DATE:	07/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:39 AM
MET WITH:	Joselito Rivera		TIME COMPLETED:	02:05 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) Jessica Cho conducted an unannounced visit to Coastside Senior Home. The purpose of today's visit was to conduct a Required 1 Year inspection focusing primarily on the Infection Control. At 9:47 am, LPA Cho was allowed entry into the facility and met with Caregiver (CG) Vivien Curry after completing the Coronavirus 2019 (COVID-19) screening procedure. Caregiver John Pratt was also present. Administrator (Admin) Joselito Rivera came downstairs from the second floor at 9:48 am. Admin lives on the second floor. As of today, there are no active COVID-19 cases in the facility. Facility screens temperature for all visitors, and LPA observed the required COVID-19 precautionary signs on the glass storage cabinet. The facility is licensed for six non-ambulatory residents. The facility also has a Hospice waiver for two residents. There are currently three residents living in the facility and two residents are in hospice care. The Administrator's Certificate for Joselito Rivera expires on 10/03/2022. At 9:50 am, LPA Cho conducted a tour of the physical plant along with Admin Rivera. The two story home consists of four resident bedrooms and one resident bathroom. There is a private staff bedroom and bathroom on the first floor. The second floor is the residence of the Admin. The facility also has a living room, family room, dining area, kitchen, and an attached garage. The three residents in the facility appeared well-groomed and well cared-for. LPA Cho observed the Complaint Poster in an incorrect sizing of 8.5" x 11" posted on the bulletin board in the hallway. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. A camera was installed in Bedroom #2 for R1 and Bedroom #4 for R2. Per Admin, the cameras were consented by both families but were removed during the visit. LPA also observed cameras in the common areas which are located in the dining area and family room. Resident bathroom was checked. Toilet and water faucet worked properly, grab bar was secure, shower was free of mold/mildew and a non-skid surface or mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps. The required hand washing signs were observed in the bathrooms. LPA Cho tested the hot water temperature in the resident bathroom and the temperature measured at 107.6 degrees Fahrenheit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

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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Document Has Been Signed on 07/21/2022 01:41 PM - It Cannot Be Edited

Created By: Jessica Cho On 07/21/2022 at 12:08 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COASTSIDE SENIOR HOME	FACILITY NUMBER: 306001961
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.2(a)(1)

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by: Based on observation and Administrator's interview, the facility utilizes a camera and is not providing R1 and R2 a reasonable level of personal privacy in their bedroom. This poses a potential health and safety risks to persons in care.
	POC Due Date: 07/28/2022
	Plan of Correction
1 2 3 4	The cameras were removed during the visit, and licensee agrees to submit an exception waiver request for the use cameras for R1 and R2 by POC due date. Licensee agrees to submit the proof of correction to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Sheila Santos

LICENSING EVALUATOR NAME:

Jessica Cho

LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: COASTSIDE SENIOR HOME	FACILITY NUMBER: 306001961
	VISIT DATE: 07/21/2022

NARRATIVE

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LPA Cho inspected the kitchen along with Admin Rivera. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The two fire extinguishers were last serviced on 02/02/2021. An appointment was scheduled with the Orange County Fire Protection via telephone during the visit. The smoke and carbon monoxide detectors were tested along with the Admin and were found to be operational. Medications, toxins, and sharps were locked and inaccessible to residents. The auditory alarms throughout the facility were in operating condition.

LPA Cho toured the outside grounds. There were no bodies of water present. There was ample shading but insufficient seating for residents. Walkways around the home were unclear and unsafe due to the backyard being surrounded with potted plants. LPA observed potted plants on all tables, seats, and walkways. The side gates were self-closing and self-latching, and there were no security bars or weapons on the premises.

LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility has back-up emergency food and water supply. The First Aid Kit had all the required components, and the facility had sufficient PPEs.

No staff files were reviewed at the time of this visit. Resident files for R1 and R2 were reviewed at the time of this visit. Admin to email the Plan of Operations to LPA by 07/25/2022. LPA Cho reviewed Assembly Bill 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. An iPad is available upon request.

LPA consulted the following: to obtain the correct sizing of the Complaint Poster (PUB475), to ensure the two fire extinguishers are serviced annually or replaced, to remove the potted plants off the tables and seats in the backyard to create a clear outdoor passageway kept free from obstruction, and to request a waiver for the use of a bedroom camera from the Department for R1 and R2.

LPA Cho reviewed the approved COVID-19 mitigation plan of the facility. A deficiency is being cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102) were also issued during the visit, and the licensee will follow-up with the corrections. An exit interview was conducted with Administrator Joselito Rivera, and a copy of this report was provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

LIC809 (FAS) - (06/04)

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