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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005880
Report Date: 02/07/2025
Date Signed: 02/07/2025 01:14:22 PM

Document Has Been Signed on 02/07/2025 01:14 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:SHORELINE SENIOR LIVINGFACILITY NUMBER:
306005880
ADMINISTRATOR/
DIRECTOR:		EDGINGTON, HEATHERFACILITY TYPE:
740
ADDRESS:7101 NIMROD DRTELEPHONE:
(714) 916-0029
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6CENSUS: 4DATE:
02/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Lady Manieda- Caregiver, Heather Edgington- AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:35 PM
NARRATIVE
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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 caregiver Marlou Babanta after explaining the purpose of the visit. Administrator (AD) Heather Edginton was notified via telephone and later arrived to assist with the visit. LPA observed the Administrator certificate was current and expires February 23, 2025. This is a Residential Care Facility for the Elderly (RCFE) licensed to six non-ambulatory residents, of which one may be bedridden, with a hospice waiver for six. The facility is a one story home with four resident bedrooms, one staff bedroom, bathroom, half bath, living room, dinning room, kitchen, and an attached garage.

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

LPA observed four residents in care and three staff present. Residents were sleeping in their respective bedrooms and living room after breakfast. LPA observed the See Something Say Something Poster (PUB 475) mounted on the wall by the entry way, however poster is not the correct size; a technical violation was issued on today’s date. All resident bedrooms had the required furnishings. LPA observed all resident beds had linens and blankets with additional linens stored in the hallway. LPA observed bathrooms were clean and equipped with grab bars and non-skid floor mats. LPA observed all windows were appropriately screened. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 105.8 and 113.4 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

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Nancy Guillen
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
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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Document Has Been Signed on 02/07/2025 01:14 PM - It Cannot Be Edited


Created By: Nancy Guillen On 02/07/2025 at 11:57 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: SHORELINE SENIOR LIVING
FACILITY NUMBER: 306005880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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 record review and staff interviews the licensee did not comply with the section cited above which poses an immediate safety risk to persons in care. Disaster Drills are not being conducted with residents or staff.
POC Due Date: 02/10/2025
Plan of Correction
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Licensee to conduct disaster drill trainings and provide log and topics discused to LPA by POC 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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2025


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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: SHORELINE SENIOR LIVING
FACILITY NUMBER: 306005880
VISIT DATE: 02/07/2025
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. LPA observed four spices to be expired; a technical violation was issued on today’s date. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged and located in the dining room. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. The garage is used for storage which is kept locked and inaccessible to residents. Toxic chemicals, cleaning solutions, and disinfectants were observed to be locked and inaccessible to residents in the garage and under the kitchen sink. Medication cabinet was observed to be locked and centrally stored in the kitchen. LPA observed the First Aid Kit had all the required components. Through staff interviews and document review LPA observed the facility has not conducted any emergency disaster drills; a deficiency was cited on today’s date. Per document review LPA observed the Emergency Plan is not being reviewed annually a technical violation was issued on todays date.

While waiting for the AD, LPA began review of the records. LPA Guillen reviewed four resident records. All the required documentation were present and current in the residents’ files reviewed. LPA reviewed four employee files. All employee’s present have a criminal record clearance and were associated to the facility, however no staff training has been done within the last year; a deficiency was issued 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 and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Nancy Guillen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/07/2025 01:14 PM - It Cannot Be Edited


Created By: Nancy Guillen On 02/07/2025 at 12:44 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: SHORELINE SENIOR LIVING
FACILITY NUMBER: 306005880

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(2)
(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 document review and staff interviews the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Staff do not have any proof of training within the last year.
POC Due Date: 02/10/2025
Plan of Correction
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Licensee to send written plan of when training will be started and completed. Licensee to provide proof of completed trainings by February 21, 2025
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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2025


LIC809 (FAS) - (06/04)
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