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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001961
Report Date: 06/25/2025
Date Signed: 06/25/2025 01:05:03 PM

Document Has Been Signed on 06/25/2025 01:05 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:COASTSIDE SENIOR HOMEFACILITY NUMBER:
306001961
ADMINISTRATOR/
DIRECTOR:		JOSELITO RIVERAFACILITY TYPE:
740
ADDRESS:3264 COLORADO LANETELEPHONE:
(714) 444-9800
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 2DATE:
06/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Joselito RiveraTIME VISIT/
INSPECTION COMPLETED:
01:18 PM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 4 residents and the home currently has 2 residents, with 1 resident on hospice. Administrator (AD) Joselito Rivera arrived shortly to conduct facility tour. AD provided updated liability insurance that expires on 2/16/2026. AD certificate expires on 10/3/2026.

LPA along with AD toured the facility at 9:05 AM. LPA toured the physical plant, checked food service, and facility documentation. The home consists of 4 resident bedrooms, living room, dining room, staff room and kitchen as well as 2 bathrooms on the first floor. The second floor consists of 3 bedrooms and living room used by the AD. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure. At 9:30 AM, LPA observed shower floor dirty with stains, transfer chair with rusted wheel brackets, and cleaning power in unlocked cabinet in resident bathroom. Water temperature measured 115.7 degrees F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. At 9:45 AM, LPA observed furniture blocking sliding door exit access in rooms 3 and 4. Three auditory exit alarms were non-operational. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. Outside grounds were toured. At 10:00 AM, LPA observed clutter in the backyard including an old mattress, other large items designated for removal as stated by AD, and various small items stacked around the house which can be difficult to navigate through. There is plant overgrowth along one of the exit paths covering a large portion of concrete.
Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Fred Arias
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/25/2025 01:05 PM - It Cannot Be Edited


Created By: Fred Arias On 06/25/2025 at 11:34 AM
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: 06/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and record review, R1 is missing medications that are not being administered which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/26/2025
Plan of Correction
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AD to obtain updated medication list and ensure all medications are accounted for and being administered as prescribed for R1. AD to create a centrally stored medication and destruction list for all residents in care. AD to email proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2025 01:05 PM - It Cannot Be Edited


Created By: Fred Arias On 06/25/2025 at 11:34 AM
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: 06/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(12)
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, there is no infection control plan available which poses a potential health and safety risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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AD to create an infection control plan and email proof to LPA by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2025 01:05 PM - It Cannot Be Edited


Created By: Fred Arias On 06/25/2025 at 11:34 AM
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: 06/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, cleaning powder accessible in the unlocked cabinet in the resident bathroom which a potential health and safety risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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AD locked cabinet during inspection. AD to hold an in-service training for staff and email proof to LPA by POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, staff 2 (S2) does not have 20 hours annual training completed within 12 months which poses a potential health and safety risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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AD to train S2 and provide proof of training to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/25/2025 01:05 PM - It Cannot Be Edited


Created By: Fred Arias On 06/25/2025 at 11:34 AM
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: 06/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(2)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, there is not sufficient emergency water available for the facility to be self-reliant for 72 hours which poses a potential health and safety risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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AD to purchase at least 10 gallons of water for emergency use. AD to email photo of water and receipt of purchase to LPA by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the facility has not conducted a disaster drill this year which poses a potential health and safety risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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AD to conduct disaster drill and email proof to LPA including the type of drill, time taken, participant names with signatures, and summary by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: COASTSIDE SENIOR HOME
FACILITY NUMBER: 306001961
VISIT DATE: 06/25/2025
NARRATIVE
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 Exit gates are unlocked and operational. First aid kit contained all required items including tweezers, scissors and thermometer. LPA observed the emergency food supply. LPA reviewed emergency disaster plan. There was no infection control plan to review. There is no evidence of disaster drills being completed this year. LPA reviewed two resident files and two staff files. All resident files contained required documentation including admission agreements, physician reports, and resident appraisals. Staff files reviewed contained required documentation including medical assessment/ TB, criminal record clearance and proof of CPR training. One out of two staff files contained proof of required training. LPA reviewed medication storage and administration. Medications are stored in a locked closet. Medication is not being administered as prescribed for resident 1 (R1).

Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided along with appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Fred Arias
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2025
LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 06/25/2025 01:05 PM - It Cannot Be Edited


Created By: Fred Arias On 06/25/2025 at 12:21 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: 06/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision maintenance services and procedures for the safety and well-being of residents, employees, and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, resident bathroom shower floor is stained and dirty, three auditory alarms in bedrooms and bathroom are not functional, furniture is blocking sliding door exits in rooms 3 and 4, transfer chair has rust in wheel brackets, there is clutter in the backyard including plant overgrowth in side exit path and large items such as mattress and other times stacked by the house which poses/posed a potential health and safety risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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Facility to clean the bathroom, repair/replace auditory alarms, remove/rearrange furniture blocking sliding doors, repair/replace transfer chair, remove bulky items and trash from the backyard, and cut plant overgrowth from the side exit path. LPA to return and verify visually on or after POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Fred Arias
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/25/2025


LIC809 (FAS) - (06/04)
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