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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881812
Report Date: 04/08/2026
Date Signed: 04/08/2026 02:06:33 PM

Document Has Been Signed on 04/08/2026 02:06 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:COASTAL HAVEN LIVINGFACILITY NUMBER:
331881812
ADMINISTRATOR/
DIRECTOR:		SU, JONAHFACILITY TYPE:
740
ADDRESS:42165 PATTON PLACETELEPHONE:
(951) 239-0671
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY: 6CENSUS: 5DATE:
04/08/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator Jonah SuTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 04/08/2026, Licensing Program Analyst (LPA) Janette Romero conducted a case management visit to address deficiencies observed while in the facility initiating an investigation into a complaint. During the visit, LPA observed five (5) residents and two (2) staff present. Administrator Jonah Su was informed of the purpose of LPA's visit and arrived to the facility to meet with LPA.

During the facility tour, LPA observed Staff 1 (S1) present in the kitchen. Administrator Su described S1 as the facility cook that periodically resides in the facility. S1 was interviewed and reported they volunteer as a facility cook and have resided in the facility on average 3-4 days per week since before the summer of 2025. LPA conducted a record review which revealed S1 does not have a criminal record clearance or approved exemption to work, volunteer, or reside in the facility. During the visit, Staff 2 (S2) was the caregiver present providing care and supervision to the residents. S2 was interviewed and reported working in the facility for the approximately the past three (3) weeks. Administrator Su reported S2 has been working in the facility for approximately one (1) week. LPA conducted a record review which revealed S2 is not associated with the facility. Administrator Su reported on 03/31/2026, Resident 1 eloped from the facility and was hospitalized. However, the facility did not verbally report the incident to Community Care Licensing or submit a written report. Based on the aforementioned, the facility will be cited and civil penalties will be assessed. No additional health or safety concerns were observed during today's visit. An exit interview was conducted and a copy of this report, Confidential Names list (LIC 811), LIC 809-D, LIC 412BG, and Appeal Rights were reviewed and provided to Administrator Su.
NAME OF LICENSING PROGRAM MANAGER: Carolyn Tuba
NAME OF LICENSING PROGRAM ANALYST: Janette Romero
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/08/2026 02:06 PM - It Cannot Be Edited


Created By: Janette Romero On 04/08/2026 at 12:00 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COASTAL HAVEN LIVING
FACILITY NUMBER: 331881812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2026
Section Cited
CCR
87355(e)(2)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department or.. This requirement was not met as evidenced by:
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Administrator Su escorted S1 out of the facility and reported S1 will not be allowed to return to the premises, indefinitely. POC met.
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During the tour, LPA observed Staff 1 (S1) present in the facility. S1 was reported to reside in the facility. LPA conducted a record review which revealed S1 does not have a criminal record clearance or approved exemption to work, volunteer, or reside in the facility. This poses an immediate health/safety risk to residents in care.
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Type B
04/15/2026
Section Cited
CCR87355(e)(3)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Obtain a California clearance or a criminal record exemption as required by the Department or.. This requirement was not met as evidenced by:
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Administrator reported they will contact the Department's Guardian Background Check System and request access to be able to associate staff with the facility.
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During the vist, Staff 2 (S2) was the caregiver present providing care and supervision to the residents. However, a record review revealed S2 is not associated with the facility. This poses a potential health or safety risk to residents in care.
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Administrator reported they will email LPA a Criminal Background Clearance Transfer Request (LIC 9182) form for S2 by close of business on 04/15/2026 if they are unable to gain access to Guardian and associate S2 through Guardian. POC to be emailed to LPA by close of business on 04/15/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Carolyn Tuba
NAME OF LICENSING PROGRAM MANAGER:
Janette Romero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/08/2026 02:06 PM - It Cannot Be Edited


Created By: Janette Romero On 04/08/2026 at 01:27 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: COASTAL HAVEN LIVING
FACILITY NUMBER: 331881812

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/30/2026
Section Cited
CCR
87211(a)(1)(D)

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(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 occurrence of any of the events specified in (A) through (D) below... (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by:
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Administrator Su agreed to contact an outside vendor to receive training for himself and all staff regarding the Department's reporting requirements pursuant to CCR 87211. Proof of training to be submitted to LPA by close of business on 04/30/2026.
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Administrator Su reported the facility did not verbally report or submit a written incident report to Community Care Licensing to report R1's elopement and hospitalization on 03/31/2026. This poses a potential health, safety or personal rights risk to residents in care.
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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.
Carolyn Tuba
NAME OF LICENSING PROGRAM MANAGER:
Janette Romero
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2026


LIC809 (FAS) - (06/04)
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