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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006070
Report Date: 03/13/2023
Date Signed: 03/13/2023 02:57:32 PM

Document Has Been Signed on 03/13/2023 02:57 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 & INLAND A/SC, 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: 2DATE:
03/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Ahmad Ali, AdministratorTIME COMPLETED:
03:15 PM
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted a case management visit in parallel to the initial complaint investigation visit for complaint reference 22-AS-20230309101851. LPA was greeted and granted entry by caregiving staff after stating the purpose of the visit. Administrator was notified of the visit by phone and arrived to assist shortly afterwards.

While reviewing the facility's records, LPA observed that staff member S1 was background cleared as well as associated to COASTAL SENIOR LIVING - 306005619 and COASTAL HOME CARE - 306004788 which are operated by the same licensee. However no staff association with the present facility were found.

LPA provided consultation to advise licensee to provide a completed form LIC508 and related documentation to the Department at the earliest convenience to proceed to the necessary association.

A Technical Assistance Advisory Note was issued. No deficiency cited at this time.

An exit interview was conducted and a copy of the report was provided to the facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2023
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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