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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006445
Report Date: 01/03/2025
Date Signed: 01/03/2025 12:34:31 PM

Document Has Been Signed on 01/03/2025 12:34 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:LA COSTA RESIDENCEFACILITY NUMBER:
306006445
ADMINISTRATOR/
DIRECTOR:		CALILUNG, VANESSA S.FACILITY TYPE:
740
ADDRESS:3016 BUCHANAN WAYTELEPHONE:
(714) 906-6046
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 4DATE:
01/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Bene Therese Molintas, Interim administratorTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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On this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Hanna Gough made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry by facility caregiving staff after introducing themselves and stating the purpose of the visit. Facility manager Bene Therese Molintas was notified by telephone and arrived later to assist with the visit.

There are currently four residents in care, two of which are receiving hospice care. LPAs observed residents relaxing in their respective bedrooms. LPAs accompanied by facility staff toured the physical plant. The facility is a one-story house with an attached garage. The facility has five bedrooms including a shared room along with two bathrooms accessed in the hallway and a third en-suite bath attached to the shared room. Additional staff dwelling are in an Additional Dwelling Unit in the backyard. Bedrooms appeared clean and sanitary. Full bed rails present in one bedroom and half rails for two other residents, orders and hospice plans of care reviewed. LPAs observed all the resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Bathrooms are equipped with grab bars and slip mats. Hot water temperature measured at 120 and 123F during the visit and was adjusted down.

LPAs observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items are stored in a secure drawer. Fire extinguishers are charged and mounted. LPAs tested the smoke and carbon monoxide detectors which were found to be operational. The centrally stored medication is located in a locked closet in the hallway. The attached garage is inaccessible to residents and is used for storage and laundry. Cleaning supplies are stored securely in the garage.

LPAs and facility staff toured the outside of the facility. LPAs observed an shaded outdoor seating areas with furniture for resident use. The perimeter gates on one side of the property is self-latching, but is locked via a padlock. Citation issued.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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 01/03/2025 12:34 PM - It Cannot Be Edited


Created By: Kevin Saborit-Guasch On 01/03/2025 at 11:37 AM
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: LA COSTA RESIDENCE
FACILITY NUMBER: 306006445

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as the exterior exit gate is secured with a padlock that prevents staff and residents from evacuating, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2025
Plan of Correction
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Padlock removed, citation cleared.
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:Sheila Santos
LICENSING EVALUATOR NAME:Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LA COSTA RESIDENCE
FACILITY NUMBER: 306006445
VISIT DATE: 01/03/2025
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CONTINUED FROM FORM LIC809

LPAs reviewed four resident records which included all necessary components. One admission agreement is for a different licensed location also operated by the licensee. Consultation provided. LPAs reviewed resident medication records and prescription orders for all four residents, no discrepancies observed. LPAs reviewed three staff records which were found to be complete. Training and CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately.

Based on the observations made during today’s visit, one type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. Four consultations provided on attached Advisory Notes form. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
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