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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006596
Report Date: 11/20/2024
Date Signed: 11/20/2024 11:08:44 AM

Document Has Been Signed on 11/20/2024 11:08 AM - 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:SUNCOAST SENIOR CAREFACILITY NUMBER:
306006596
ADMINISTRATOR/
DIRECTOR:		ALBU, CIPRIANFACILITY TYPE:
740
ADDRESS:13702 MARSHALL LNTELEPHONE:
(714) 425-1816
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 0DATE:
11/20/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Ciprian AlbuTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On November 20, 2024, at 8:00am, Licensing Program Analyst (LPA) Edward Kim conducted an announced visit to the facility to conduct the pre-licensing inspection. LPA Kim met with Applicant Ciprian Albu and toured the facility.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) was submitted to CCL on July 1, 2024. The facility has the capacity of six (6) residents, five (5) can be nonambulatory and one (1) may be bedridden. Applicant has requested a hospice waiver for two (2) residents. Facility phone number (714-425-1816). LPA Kim observed the following.

Structure:
The facility is a one-story house with an attached 2 car garage with six (6) resident bedrooms, one (1) caregiver bedroom, five (5) bathrooms, office, dining room, a kitchen, a living room, and an attic above the garage. There are six (6) exits: one exit door in the dining room, one in the main entrance, one in bedroom #4 which is the bedridden room, one in bedroom #3, one in bedroom #2, and one in bedroom #1.

Air/Heating:
Central air/heating system installed with a central panel to control entire house located next to the caregiver bedroom.

Resident Bedrooms:
There are six (6) Resident Bedrooms: Bedroom #1, Bedroom #2, Bedroom #3, Bedroom #4, Bedroom #5, and Bedroom #6. The bedrooms are spacious and will easily accommodate the residents' belongings. All resident rooms had the required furnishings.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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: SUNCOAST SENIOR CARE
FACILITY NUMBER: 306006596
VISIT DATE: 11/20/2024
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Staff Bedrooms:
There is one (1) Staff Bedroom with a sign displaying “Employees only,” next to resident bedroom #1.

Bathrooms:
All bathrooms have a working toilet, wash basin and shower. All bathrooms are clean. Shower mats were in all three bathrooms. Hot water was measured in all bathrooms. Hot water measured between 115.1 degrees Fahrenheit to 118.2 degrees Fahrenheit.

Linens & Hygiene Supplies:
Adequate supply of linen stored in hallway cabinets.

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed and posted in the entrance hallway. Menus posted and available next to the emergency information in entrance hallway.

Food Service:
There are no residents living in the facility currently. There is a 2-day perishable food. There is 7-day non-perishable food supply on hand. The emergency food, emergency water, and emergency supplies are stored in the garage.

Toxins:
All cleaning supplies and chemicals are kept in the garage and locked underneath the kitchen sink.

Resident & Staff Files:
The Resident and Staff Records will be kept locked in filing cabinet in the dining room.
Outdoor/Yard:
There is an outdoor furniture with an umbrella to cover the table and chairs in the front. All outdoor gates are self-closing and self-latching.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
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: SUNCOAST SENIOR CARE
FACILITY NUMBER: 306006596
VISIT DATE: 11/20/2024
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Smoke Detectors/Carbon Monoxide Detectors:

Smoke detectors/carbon monoxide detectors are hardwired and tested operational. There is a fire extinguisher mounted on the wall in the kitchen. The fire extinguisher is fully charged and was serviced on July 26, 2024.


Medications, First-Aid Kit & Book:
The first aid kit and all medications are stored in medical cabinet, which is in the kitchen to the right of the oven. The first aid kit has all the required elements. The cabinet is kept locked.

Reading Material, Games, Equipment & Materials:
Art supplies and board games are stored in the kitchen cabinet next to the dining room exit. There is a large screen TV in the living room. Each bedroom has individual large screen TV.

Appliances:
There is one four (4) gas burner stove which lights unassisted, two ovens, microwave oven, a refrigerator in the kitchen, a refrigerator in the garage, toaster, air fryer, two coffee machines, dishwasher, washer, and dryer. All appliances are clean and operational.

Fire clearance:
Fire Clearance approved by Orange County Fire Authority on August 15, 2024.

Component III:
Component three was completed with Applicant Ciprian Albu during visit.

The pre-licensing visit and Component III Orientation are now complete. It appears this facility meets the requirements for licensure. LPA Kim will forward this report to the Centralized Applications Bureau for review. The license will be granted upon completion of a final review and approval from the Centralized Applications Bureau.

Exit interview was conducted and a copy of this report was left with Applicant Ciprian Albu
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Edward Kim
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2024
LIC809 (FAS) - (06/04)
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