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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005597
Report Date: 04/04/2022
Date Signed: 04/04/2022 01:16:47 PM

Document Has Been Signed on 04/04/2022 01:16 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:COAST SENIOR CARE 3FACILITY NUMBER:
306005597
ADMINISTRATOR:VIANA, KRISTENFACILITY TYPE:
740
ADDRESS:6822 MARILYN DRTELEPHONE:
(714) 470-0194
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6CENSUS: 6DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Kristen ViannaTIME COMPLETED:
01:35 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted, granted entry into the facility by Staff and explained the reason for the visit.

During the visit LPA toured the facility at 11:50 AM with Caregiver Red Galdones Facility is a 6 bedroom,(5 resident rooms 1 staff bedroom) and 3 bathrooms single story home. There are 6 Residents in care. LPA observed proper covid signage at front entrance of facility as well as a sign in, sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring June 16, 2022. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper, and paper towels. Residents were observed relaxing in the Living room watching TV and relaxing in bedrooms. Facility has 1 fire extinguisher that is mounted and charged. Facility has supply of PPE. Facility has 2 refrigerators and pantry with ample food supply. LPA observed facility has emergency food and water supply. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for Residents. LPA reviewed Residents files during visit. Residents emergency contact information and Physicians reports are current. Facility has several designated visitation areas.

No deficiencies noted during todays visit. An exit interview was conducted with Administrator Kristen Vianna and a copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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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