<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006070
Report Date: 10/08/2021
Date Signed: 10/15/2021 09:19:56 AM

Document Has Been Signed on 10/15/2021 09:19 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:COASTAL CHARM OF TUSTINFACILITY NUMBER:
306006070
ADMINISTRATOR:ALI, AHMADFACILITY TYPE:
740
ADDRESS:13341 ETON PLACETELEPHONE:
(949) 357-7633
CITY:NORTH TUSTINSTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 0DATE:
10/08/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Ali AhmadTIME COMPLETED:
12:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Michelle Reed arrived at the facility to commence an announced Prelicensing visit. Upon arrival, LPA met with Applicant Ahmad Ali. This is a relocation of facility Coastal Home Care #306004788 in San Clemente. An initial application to operate an Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 8/30/21 for a capacity of 6 nonabmulatory residents of which 5 will be non-ambulatory and 1 bedridden. The Orange County Fire Authority conducted a Fire Safety Inspection on 9/14/21 and granted a fire clearance. A tour of the physical plant was conducted inside and out at approximately 11:20 am. with Mr. Ali and the following was observed:
Structure:
Facility is a one story house with 7 bedrooms and 3 bathrooms. Bedroom #1 through #5 are designated as resident rooms and are authorized for non-ambulatory resident use. Bedroom #1 will be used for the bedridden room. There is also a living room, dining area and kitchen. Staff rooms are Rooms #6 and #7.
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.
Bathrooms:
Bathrooms have a working toilet, wash basin, and shower. Grab bars and non-slip mats were present as well as soap, paper towels and toilet paper.
Linens and Hygiene Supplies:
Adequate supply of linens and hygiene supplies were observed
Ombudsman Poster, Personal Rights and See Something Say Something Poster
Required posters are present
Food Service:
Adequate supply of 7-day non-perishable and 2 day perishables will be stored in the kitchen and pantry and include fruits and vegetables.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: COASTAL CHARM OF TUSTIN
FACILITY NUMBER: 306006070
VISIT DATE: 10/08/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Smoke and Carbon Monoxide Detectors:
Smoke detectors and carbon monoxide systems were observed working at the time of this visit
Fire Extinguishers:
Fire Extinguishers were present and were mounted and fully charged at the time of this visit
Appliances:
Refrigerator/freezer and microwave which were clean and noted to be operational. Washer and dryer were present, however were not installed.
Toxins:
Will be locked and inaccessible to residents
Water Temperature:
Tested and recorded at 124 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. LPA also discussed importance of Department PINs, reporting requirements.
Infection Control
Infection Control Measures were in place.

Applicant will need to provide Proof of Correction for the following before Licensure. LPA will be conducting a Plan of Correction visit to followup:
1) Facility needs to be cleaned. Facility needs to be dusted, walls wiped down and carpet cleaned. Proof will need to be provided via certification and receipt that rugs were professionally cleaned.

2) Water temperature will need to be between regulation guidelines and proof provided.

3) Certification provided that washer and dryer have been installed and are in operating condition.

The Licensee will be granted when all POC's are completed and 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 Mr. Ali.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2