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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005767
Report Date: 05/21/2021
Date Signed: 05/21/2021 04:01:22 PM

Document Has Been Signed on 05/21/2021 04:01 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:TRANQUILITY SENIOR LIVINGFACILITY NUMBER:
306005767
ADMINISTRATOR:BRYANT II, LANCEFACILITY TYPE:
740
ADDRESS:285 E 22ND STTELEPHONE:
(949) 331-2744
CITY:COSTA MESASTATE: CAZIP CODE:
92627
CAPACITY: 6CENSUS: 6DATE:
05/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lance BryantTIME COMPLETED:
04:15 PM
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This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Norman C. Woodridge for the purpose of conducting an Annual Inspection. LPAs met with Administrator (AD) Lance Bryant and discussed the purpose of the inspection. During the inspection, LPAs and AD conducted a tour of the inside of the facility, common areas, resident rooms, and kitchen and observed the following:

At 2:00 PM, LPAs observed there were 2 staff present, all wearing PPE. LPA observed 6 residents were present. LPAs confirmed all residents were doing well and observed no health and safety issues. LPAs inspected common areas, resident rooms, and kitchen, and observed they were clean and organized, and found no health and safety issues. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction.

LPAs reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, staffing, infection control/lead/training, PPE, staffing and staffing shortages, communication and emergency plan, and memory care. LPAs provided technical assistance regarding PPE usage, COVID-19 signage, and N95 fit testing. LPAs requested and reviewed resident roster, staff roster, resident files, emergency plan, and COVID-19 mitigation plan.

There were no health and safety concerns observed in the areas inspected. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 of the California Code of Regulations. An exit interview was conducted and a copy of this report was discussed with and provided to facility representative.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2021
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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