<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003408
Report Date: 03/25/2025
Date Signed: 03/25/2025 12:51:41 PM

Document Has Been Signed on 03/25/2025 12:51 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:OCEAN RETREATFACILITY NUMBER:
306003408
ADMINISTRATOR/
DIRECTOR:		CARINA DEMMANFACILITY TYPE:
740
ADDRESS:6021 PRISCILLA DRIVETELEPHONE:
(714) 898-2646
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6CENSUS: 4DATE:
03/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:Administrator- Carina DemmanTIME VISIT/
INSPECTION COMPLETED:
01:15 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) Nancy Guillen made an unannounced visit for the purpose of conducting a required annual Inspection. LPA was greeted and granted entry by care provider Ace Reblora after explaining the purpose of the visit. Administrator (AD) Carina Demman was notified via telephone and later arrived to assist with record review. LPA observed the Administrator certificate was current and expires December 12, 2025. This is a Residential Care Facility for the Elderly (RCFE) licensed to six non-ambulatory residents with a hospice waiver for three. The facility is a one story home with three resident bedrooms, one staff bedroom, two bathrooms, kitchen, living room, dinning room, office space, and an attached garage.

During the inspection, LPA and caregiver conducted a tour of the inside and outside of the facility and observed the following:

LPA observed residents watching television in the living room. LPA observed four residents in care and three staff present. LPA observed the See Something Say Something Poster (PUB 475) mounted on the wall by the facility entrance. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets with additional linens stored in the hallway storage cabinet. LPA observed bathrooms were clean and equipped with grab bars and non skid floor mats. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 106.7 and 109.5 degrees Fahrenheit. LPA toured the outside of the facility and observed outdoor passageways were free of obstruction. LPA observed the backyard had a shaded sitting area with furniture for resident use.

Continued on LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 03/25/2025 12:51 PM - It Cannot Be Edited


Created By: Nancy Guillen On 03/25/2025 at 11:38 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: OCEAN RETREAT
FACILITY NUMBER: 306003408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above, which poses an immediate health and safety risk to persons in care. Toxins/cleaning supplies were observed under bathroom sink, hallway closet, and outdoor patio. Additional medications stored in kitchen cabinet did not have a locking mechanism.
POC Due Date: 03/26/2025
Plan of Correction
1
2
3
4
Caregiver removed all accessible toxic chemicals and placed them in locked cabinets. This POC was cleared on today's visit.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and staff interview, the licensee did not comply with the section cited above in four out of four resident's medications due to medication being pre-poured 1 week in advanced, which poses an immediate health risk to persons in care.
POC Due Date: 03/26/2025
Plan of Correction
1
2
3
4
Licensee stated medication will no longer be pre-poured and an inservice training will be conducted. Licensee to send LPA written plan of how medication will be admisitered to residents safely by POC due date via email to LPA.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/25/2025 12:51 PM - It Cannot Be Edited


Created By: Nancy Guillen On 03/25/2025 at 11:38 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: OCEAN RETREAT
FACILITY NUMBER: 306003408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in three out of three fire extinguishers due to not being serviced since June 29,2023, which poses a potential safety risk to persons in care.
POC Due Date: 04/07/2025
Plan of Correction
1
2
3
4
Licensee stated a new fire extinguisher will be purchased and an image of item and receipt will be sent to LPA by POC due date via email.
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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in one out of three records reviewed due to staff # 2 not having annual training, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 04/07/2025
Plan of Correction
1
2
3
4
Licensee stated annual training will be conducted for Staff #2 and sent to LPA via email 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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/25/2025 12:51 PM - It Cannot Be Edited


Created By: Nancy Guillen On 03/25/2025 at 11:38 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: OCEAN RETREAT
FACILITY NUMBER: 306003408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above due to not conducting/logging disaster training, which poses a potential health and safety risk to persons in care.
POC Due Date: 04/07/2025
Plan of Correction
1
2
3
4
Licensee to conduct and log disaster drill and continue conducting drill quarterly. Licensee to send log to LPA via email by POC due date.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in two out of four records reviewed due to resident's not having doctor's orders for hospital beds and bed rails, which poses a potential safety risk to persons in care.
POC Due Date: 04/07/2025
Plan of Correction
1
2
3
4
Licensee to send doctor's orders for Resident #3's hospital bed and Resident 1 to remove hosipital bed an 1/2 bed rail by POC dude date. Images to be sent to LPA via email.

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:Armando J Lucero
LICENSING EVALUATOR NAME:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
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: OCEAN RETREAT
FACILITY NUMBER: 306003408
VISIT DATE: 03/25/2025
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
26
27
28
29
30
31
32
LPA observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be last purchased on June 29, 2023; a deficiency was cited on today’s date. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. The garage is used for storage and inaccessible to residents. Toxic chemicals, cleaning solutions, and disinfectants were observed throughout the facility. Toxins/cleaning supplies were observed under bathroom sink, hallway closet, and outdoor patio. Kitchen cabinet was also observed to be used for additional medication storage and did not have a locking mechanism and knives were observed in an unlocked cabinet accessible to residents in care; a deficiency was cited on today’s date. Medication was observed in the office space of the facility however, medication is pre-poured a week in advanced in a weekly container; a Deficiency was cited on this date. LPA observed the First Aid Kit had all the required components. LPA observed disaster drills are not logged and was unavailable for review; a deficiency was cited on today’s date.

While waiting for the AD, LPA began review of the records. LPA Guillen reviewed four resident records. All the required documentation was present and current in the residents’ files reviewed, however Resident 1 and Resident 2 did not have doctor’s orders present for hospital bed and rails at the facility for review; a deficiency was cited on today’s date. LPA reviewed two employee records. All employee’s present have a criminal record clearance and were associated to the facility. LPA observed records reviewed have a current First Aid certificate. Staff #2 however did not have yearly training completed, a deficiency was cited on today’s date.



Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report, LIC 809D and appeal rights was left at the facility.
NAME OF LICENSING PROGRAM MANAGER: Armando J Lucero
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6