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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006518
Report Date: 05/23/2024
Date Signed: 05/23/2024 03:37:33 PM

Document Has Been Signed on 05/23/2024 03:37 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:SUNNY COAST CARE HOMEFACILITY NUMBER:
306006518
ADMINISTRATOR/
DIRECTOR:		BULLER, KATHRINAFACILITY TYPE:
740
ADDRESS:1615 KENT LANETELEPHONE:
(714) 749-9353
CITY:NEWPORT BEACHSTATE: CAZIP CODE:
92660
CAPACITY: 6CENSUS: 6DATE:
05/23/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:31 PM
MET WITH:Kathrina Buller-LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:53 PM
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Licensing Program Analysts (LPA) Alvaro Ramirez, Jr. conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA met with Applicant Katrina Buller and toured the facility.

An application for Change of Ownership (CHOW) to operate a Residential Care Facility for the Elderly (RCFE) was submitted to Community Care Licensing (CCL) on February 14, 2024. The facility is to have a capacity of six, of which five can be nonambulatory and one bedridden. Facility phone number 714-749-6629. LPA observed the following.

Structure:
The facility is a one-story house with five resident bedrooms, three full size bathrooms, one half bathroom, a living room, a kitchen, a dining room, and an attached car garage. LPA observed the See Something, Say Something poster (PUB 475) in the facility mounted on the wall in the entranceway. There is a backyard with an exit gate on each side of the house. There is a shaded seating area and LPA did not observe any obstacles or hazards in the backyard.

Air/Heating:
Central air/heating system installed with a central panel to control entire house.

Resident Bedrooms:
There are five resident bedrooms. All resident bedrooms had the required furnishings. LPA observed all beds had linens and blankets.


CONTINUED ON LIC809-C...
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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 3
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: SUNNY COAST CARE HOME
FACILITY NUMBER: 306006518
VISIT DATE: 05/23/2024
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Bathrooms:
All bathrooms are clean and have working plumbing. Hot water measured between 108.3 and 109.5 degrees Fahrenheit.

Linens & Hygiene Supplies:
A supply of extra linen for each resident was stored in a closet by the resident's bedrooms hallway.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menu was posted and available. Monthly menu available and posted by the resident's bedrooms hallway.

Food Service:
There are six residents living in the facility at this time. A supply of 2-day perishable and 7-day of non-perishable food was observed and will be maintained on hand.

Smoke Detectors/Carbon Monoxide Detectors:
Smoke detectors/carbon monoxide detectors are hardwired and tested operational. There is a fire extinguisher mounted on the wall by the laundry room and one by the resident's bedroom hallway.

Appliances:
There is one, four gas burner stove which lights unassisted, one oven, one microwave, a refrigerator, dishwasher, washer, and dryer. All appliances are clean and operational.

Toxins:
All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents and will be stored in the laundry room.

Water Temperature:
Hot water was measured in all bathrooms. Hot water measured between 108.3 and 109.5 degrees Fahrenheit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: SUNNY COAST CARE HOME
FACILITY NUMBER: 306006518
VISIT DATE: 05/23/2024
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Medications, First-Aid Kit & Book:
The first aid kit and the first aid manual are stored in the closet by the resident's bedrooms hallway. The first aid kit has all the required elements. Medications will be stored in a locked cabinet by the resident's bedrooms hallway.

Resident & Staff Files:
The Resident and Staff Records will be kept in a locked cabinet by the resident's bedrooms hallway.

Reading Material, Games, Equipment & Materials:
Arts and craft and board games are stored in a cabinet by the main entrance. There is one large screen television in the living room.

Fire clearance:
Fire Clearance approved by a fire inspector of Orange County Fire Authority on April 04, 2024. Special conditions noted, "Hallway door located at entrance to bedrooms shall remain closed, maintaining sliding doors to slide open easily, keep exit doors free from obstructions."

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within compliance and reporting requirements.


The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued. Applicant was informed today that the final approval will be processed by CAB (Central Applications Bureau) in Sacramento.

Exit interview was conducted and a copy of this report was left with the applicant
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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