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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006404
Report Date: 05/29/2024
Date Signed: 05/29/2024 04:57:30 PM

Document Has Been Signed on 05/29/2024 04:57 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 COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:COAST SENIOR CARE, 1FACILITY NUMBER:
306006404
ADMINISTRATOR/
DIRECTOR:		VIANA, KRISTENFACILITY TYPE:
740
ADDRESS:19861 CARMANIA LNTELEPHONE:
(714) 470-0194
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 5DATE:
05/29/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:Caregivers, Reynoldo Avena and Mitzi AvenaTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On this day Licensing Program Analysts (LPAs) Jenifer Tirre and Jessica Cho made an unannounced visit for the purpose of conduct a collateral joint visit in connection to open complaint investigations at Coast Senior Care #306005260 related to the current licensee. Facility Coast Senior Care closed and changed location as of January 30, 2024. LPAs met with Caregivers Reynaldo and Mitzi Avena and explained the reason for the visit. Administrator Kristen Viana was unavailable to be physically present during the visit and spoke to LPA's via telephone designating staff to assist with the visit.

During today’s visit, LPAs Tirre and Cho conducted interviews and gathered pertinent resident records housed at this facility related to Complaint Control Numbers:
· 22-NP-20210803071759
· 22-AS-20211208162350

An exit interview was conducted with Administrator via telephone. A copy of report was left at facility.
SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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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