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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005597
Report Date: 04/16/2026
Date Signed: 04/17/2026 11:08:53 AM

Document Has Been Signed on 04/17/2026 11:08 AM - 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:COAST SENIOR CARE 3FACILITY NUMBER:
306005597
ADMINISTRATOR/
DIRECTOR:		VIANA, KRISTENFACILITY TYPE:
740
ADDRESS:6822 MARILYN DRTELEPHONE:
(714) 470-0194
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6CENSUS: 5DATE:
04/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Renato GaldonesTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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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 Renato Galdones after explaining the purpose of the visit. LPA observed the administrator certificate was current with an expiration date of June 16, 2026. This is a Residential Care Facility for the Elderly (RCFE) licensed to six non-ambulatory residents and an approved hospice waiver for four. The facility is a one-story home with five resident bedrooms, one staff bedroom, three restrooms, a living room, dining room, kitchen and two car garage.

During the inspection, LPA and staff conducted a tour of the inside and outside of the facility, common areas, resident rooms, garage and observed the following:

LPA observed five resident in care and two staff present. LPA observed the See Something Say Something Poster (PUB 475) mounted on the wall in the living room. LPA observed that all resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets with additional linens stored in the garage. LPA observed bathrooms were clean and equipped with grab bars, toilet paper, paper towels, and non-skid floor mats. Bathrooms were observed to be free of debris and mildew. Faucets and toilets were tested operational. Water temperature tested between 115 and 119.1 degrees Fahrenheit. LPA observed all windows were appropriately screened. 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: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/16/2026
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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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: COAST SENIOR CARE 3
FACILITY NUMBER: 306005597
VISIT DATE: 04/16/2026
NARRATIVE
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LPA observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Gas stove, dish washer, microwave, washer and dryer were inspected and observed to be operable. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with a service date of February 2026 and is located in the kitchen, staff room, and garage. Toxic chemicals, cleaning solutions, and disinfectants were observed to be locked and inaccessible to residents under the kitchen sink. Medication cabinet was observed to be locked and centrally stored in a dining room cabinet. LPA observed the First Aid Kit had all the required components. LPA observed the facility conducted their last emergency disaster drill on March 17, 2026.

LPA began review of the records. LPA reviewed five resident records. All the required documentation was present and current in the residents files reviewed except for a signed copy of the Personal Rights of Residents form which was not signed by R1. LPA reviewed two employee records. All employees present have a criminal record clearance and were associated to the facility. LPA observed records reviewed have a current First Aid certificate. Upon record review LPA observed the Emergency Disaster Plan was not updated or reviewed since August 14, 2020; a deficiency was cited on today’s date. Facility was unable to provide proof of liability insurance; 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 809C, LIC 809D, LIC 858, LIC 859, LIC 9102, Appeal Rights and the Legionnaire’s Disease fact sheet was left at the facility.

NAME OF LICENSING PROGRAM MANAGER: Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM ANALYST: Nancy Guillen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/17/2026 11:08 AM - It Cannot Be Edited


Created By: Nancy Guillen On 04/16/2026 at 11:39 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: COAST SENIOR CARE 3
FACILITY NUMBER: 306005597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review the licensee did not comply with the section cited above which poses a potential rights risk to persons in care. LPA observed Resident 1 (R1) file to not have a signed copy of the the Personal Rights of Residents form.
POC Due Date: 05/06/2026
Plan of Correction
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Licensee to email proof of liability insurance to LPA by POC date.
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in which poses a potential safety risk to persons in care. LPA observed the Emergency Disaster Plan has not been reviewed/signed since August 14, 2020.
POC Due Date: 05/06/2026
Plan of Correction
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Licensee to review, update and sign Emergency Disaster Plan and send to LPA by POC 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.
Kevin Saborit-Guasch
NAME OF LICENSING PROGRAM MANAGER:
Nancy Guillen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2026


LIC809 (FAS) - (06/04)
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