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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005895
Report Date: 12/12/2024
Date Signed: 12/12/2024 05:10:13 PM

Document Has Been Signed on 12/12/2024 05:10 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:BEACH HOMES IVFACILITY NUMBER:
306005895
ADMINISTRATOR/
DIRECTOR:		BEACH, ANDREWFACILITY TYPE:
740
ADDRESS:2201 FRANSISCO DR.TELEPHONE:
(949) 612-8019
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY: 6CENSUS: 6DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Andrew BeachTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrators Andrew Beach, Patricia Beach and Nancy Ayala were notified of the visit via telephone and arrived later to assist.

LPA accompanied by facility staff conducted a tour of the physical plant and observed the following: the facility is a one-story home with an attached garage. The facility has a total of six single bedrooms in addition to a staff room. There are five en-suite bathrooms and one en-suite bathroom in the facility. All bathrooms are observed to be equipped with grab bars and slip mats. All resident bedrooms have the required furnishings. Bathrooms faucets and toilets are operational. Water temperature was measured at 114F in the shared bathroom used for personal hygiene. LPA observed all beds have linen and blankets.

There are currently six residents admitted to the facility, none of which is receiving hospice care. LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. Drills have been conducted quarterly in 2024 with documentation to be provided by licensee via email. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke and carbon monoxide detectors tested operational. Fire extinguishers present are fully charged and have been maintained in 2024.

There is adequately shaded outside space with outdoor furniture present. There are self-latching gates on each side of the property. The routes of egress on both sides are free of obstructions. There are no bodies of water on the premises.

Cleaning products are observed to placed in a cabinet under the kitchen sink, lock appears to be missing. The medication central storage is in a cabinet in the kitchen also, however the lock on the right door is not functional as observed during the visit. Type B citation issued. CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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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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: BEACH HOMES IV
FACILITY NUMBER: 306005895
VISIT DATE: 12/12/2024
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CONTINUED FROM FORM LIC809
Medication central storage reviewed for accuracy. No discrepancies observed with the physician orders on file. LPA reviewed six resident files along with three staff files. Two physician reports for residents diagnosed with dementia have been established in October 2023 and will need to be updated. Technical Violation Advisory Note issued. Resident records otherwise include all necessary components. All staff members present are confirmed to have received background clearance. Training verified to be up to date. CPR training documentation on file. Health screenings are on file for staff members reviewed.

Based on the observations made during today’s inspection, one type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. One Technical Violation and one Technical Assistance Advisory Notes issued regarding physician report updates

An exit interview was conducted and a copy of this report along with appeal rights was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/12/2024 05:10 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 12/12/2024 at 04:50 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: BEACH HOMES IV
FACILITY NUMBER: 306005895

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation conducted during the tour of the physical plant, two cabinets containing medication and supplements as well as laundry detergent stored in the staff bedroom were left accessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/31/2024
Plan of Correction
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Licensee will repair or replace the locks on both cabinets as well as install a lock on the staff bedroom door. Documentation to be provided to LPA before the plan of corrections due 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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2024


LIC809 (FAS) - (06/04)
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