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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006070
Report Date: 12/03/2024
Date Signed: 12/03/2024 03:56:04 PM

Document Has Been Signed on 12/03/2024 03:56 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:COASTAL CHARM OF TUSTINFACILITY NUMBER:
306006070
ADMINISTRATOR/
DIRECTOR:		ALI, AHMADFACILITY TYPE:
740
ADDRESS:13341 ETON PLACETELEPHONE:
(949) 357-7633
CITY:NORTH TUSTINSTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 2DATE:
12/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Ahmad AliTIME VISIT/
INSPECTION COMPLETED:
04:10 PM
NARRATIVE
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This unannounced inspection is being conducted by Licensing Program Analysts (LPAs) Sean Haddad and Eboni Bentley for the purpose of conducting a Required – 1 Year Inspection. LPAs met with Administrator (AD) Ahmad Ali and discussed the purpose of the inspection.

LPAs reviewed Infection Control requirements. At about 1:00PM, LPAs and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following: Structure: facility is a 7-bedroom, 4-bathroom, one-story house with an attached garage that is used for storage. There is a back yard with a patio cover for the residents. LPAs and AD observed 1 staff and 2 residents present at the facility. Resident Bedrooms: the 5 resident bedrooms are spacious and will easily accommodate the residents’ furnishings. Furniture for each resident bedroom inspected. Staff Bedrooms: LPAs inspected the two staff bedrooms. Bathrooms: the bathrooms were clean, faucets and toilets were operational. Water temperature: tested 113 degrees and 120 degrees F in the three resident bathrooms. Linens & Hygiene Supplies: new linens and fully stocked linen closets were observed. Emergency Phone Numbers, Exit Plan & Menu: reviewed. Food Service: LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher: observed and tested. Appliances: stove burners, microwave, washer, and dryer inspected. Knives: observed locked in the kitchen. Toxins: observed locked in the garage and shed, after correction. Medication cabinet: observed to be locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 2:30PM, LPAs reviewed 2 resident files and 2 staff files, interviewed 2 residents and 2 staff, and inspected medications for 2 residents. Facility does not handle resident money.

CONTINUED
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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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Document Has Been Signed on 12/03/2024 03:56 PM - It Cannot Be Edited


Created By: Sean Haddad On 12/03/2024 at 03:38 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: COASTAL CHARM OF TUSTIN
FACILITY NUMBER: 306006070

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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, the licensee did not ensure laundry detergent and bleach were inaccessible in the non-lockable garage and paints and tools were inaccessible in the non-lockable side shed, which poses an immediate safety risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
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During the inspection, the licensee secured these items and LPA confirmed. Licensee stated they will train staff on securing dangerous items and submit proof to LPA by 12/10/24.
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:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/03/2024 03:56 PM - It Cannot Be Edited


Created By: Sean Haddad On 12/03/2024 at 03:38 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: COASTAL CHARM OF TUSTIN
FACILITY NUMBER: 306006070

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee's 2 fire extinguishers have not been inspected in the last year, which poses a potential safety risk to persons in care.
POC Due Date: 12/10/2024
Plan of Correction
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Licensee stated they will have the fire extinguishers inspected or purchase new ones and submit proof to LPA by POC due date.
Type B
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 documents, the licensee has not conducted an emergency disaster drill since March 2024, which poses a potential safety risk to persons in care.
POC Due Date: 12/10/2024
Plan of Correction
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Licensee stated they will conduct an emergency disaster drill immediately and submit proof to LPA by POC due date and will conduct emergency disaster drills quarterly moving forward.
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:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2024


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: COASTAL CHARM OF TUSTIN
FACILITY NUMBER: 306006070
VISIT DATE: 12/03/2024
NARRATIVE
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During the inspection, LPAs and AD observed the following: based on observations, the licensee's 2 fire extinguishers have not been inspected in the last year; based on observation, the licensee did not ensure laundry detergent and bleach were inaccessible in the non-lockable garage and paints and tools were inaccessible in the non-lockable side shed; based on documents, the licensee has not conducted an emergency disaster drill since March 2024.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
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