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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005959
Report Date: 06/03/2021
Date Signed: 06/10/2021 11:45:18 AM

Document Has Been Signed on 06/10/2021 11:45 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:SILVER COAST LIVINGFACILITY NUMBER:
306005959
ADMINISTRATOR:SHARIFAN, MONELIFACILITY TYPE:
740
ADDRESS:13611 WHEELER PLACETELEPHONE:
(949) 302-2830
CITY:NORTH TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 0DATE:
06/03/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Moneli SharifanTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Michelle Reed contacted the facility via telephone to commence an announced Prelicensing visit. Upon arrival, LPA met with Moneli Sharifan. An initial application to operate an Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 1/25/21 for a capacity of 6 residents of which 1 may be bedridden. The Orange County Fire Department conducted a Fire Safety Inspection on 3/3/21 and granted a fire clearance. A tour of the physical plant was conducted inside and out at approximately 9:30am with Ms. Sharifan and the following was observed:
Structure:
Facility is a one story house with 5 bedrooms and 3 bathrooms. There is a gate that slides across the driveway of the house. Ms. Sharifan understands that the gate may not be locked as the facility was not approved for locked perimeters. Side gates for exits also may not be locked. Bedroom #1 through #5 are designated as resident rooms and are authorized for non-ambulatory resident use. There is also a living room, dining area and kitchen. There a staff room next to the kitchen and laundry room.
Signal System:
Central air/heating system installed with a central panel to control entire house.
Bedrooms Residents:
The resident bedrooms( #1-#5) accommodate residents' furnishings and meet Title 22 regulation at this time. Bedrooms with stair exits have hand rails and ramps were present and will be installed.
Bathrooms:
3 bathrooms have a working toilet, wash basin, and shower. The 3rd bathroom is for staff and visitors only. Grab bars and non-slip mats were present.
Linens and Hygiene Supplies
Adequate supply of linens and hygiene items were observed
Ombudsman Poster, Personal Rights and See Something Say Something Poster
Applicant will request an Ombudsman poster. Personal Rights and See Something Say Something were posted.
Food Service:
Adequate supply of 7-day non-perishable and 2 day perishables will be stored in the kitchen and pantry and will include fruits and vegetables.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SILVER COAST LIVING
FACILITY NUMBER: 306005959
VISIT DATE: 06/03/2021
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Smoke and Carbon Monoxide Detectors:
Smoke detectors and carbon monoxide systems were observed working at the time of this visit
Fire Extinguishers:
The fire extinguisher was mounted and fully charged at the time of this visit
Fire Clearance:
Approved on 3/3/21
Appliances:
Refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer were clean and noted to be operational.
Toxins:
Will be locked and inaccessible to residents
Water Temperature:
Tested and recorded at 118 degrees F.
Medications, First Aid Kit & Manual:
First Aid kit with guide will be stored with resident medications. Medication will be stored and locked in the facility living area.
Resident and Staff Files:
Records will be kept locked for privacy
Component III
Component III was conducted

The Prelicensing is complete and this facility has no deficiencies.

The Licensee will be granted upon a final review by the Central Applications Bureau and approval by management.

An exit interview was conducted and a copy of this report was provided to Moneli Sharifan..
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
LIC809 (FAS) - (06/04)
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