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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006404
Report Date: 03/19/2025
Date Signed: 03/19/2025 03:51:11 PM

Document Has Been Signed on 03/19/2025 03:51 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:
7144700194
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 4DATE:
03/19/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Mitzi AvenaTIME VISIT/
INSPECTION COMPLETED:
04:30 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) Ruth Martinez made an unannounced visit to the facility today in conjunction with a complaint investigation. LPA were greeted by caregiver and was granted entry. LPA met with Mitzi Avena and explained the nature of the visit.

This visit is to issue a citation for violation observed during the investigation of complaint number 22-AS-20240306093154. Interviews conducted with facility staff indicated that resident (R1) in November 2023 became more agitated, bullied staff and other residents, punched staff and resident and complained of pain even when they did not have pain. LPA did not find any LIC624 incident submitted by the facility for the changes that were observed.



Based on the information obtained there is a deficiency issued and are noted on the attached LIC809-D form.
This report is being reviewed with facility representative and a copy of this LIC809, LIC809-C and LIC809-D was provided and left at facility. Appeals Rights reviewed and a copy left at facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
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
Document Has Been Signed on 03/19/2025 03:51 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Ruth Martinez On 03/19/2025 at 02:48 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: COAST SENIOR CARE, 1
FACILITY NUMBER: 306006404

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
04/02/2025
Section Cited
CCR
87211(a)(1)

1
2
3
4
5
6
7
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurence of any of the
1
2
3
4
5
6
7
Administrator to ensure to report to CCL all conditions specified in section cited. Administrator to provide in-service training to all staff on cited regualtion. Provide proof of scheduled in-service training and copies of attendance to LPA by POC due date.
8
9
10
11
12
13
14
events specified in (A) through (D) below... This requirement is not met as evidenced by: LPA did not find any LIC624 incident submitted by the facility for the changes that were observed for R1.This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Ruth Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2