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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604726
Report Date: 01/18/2024
Date Signed: 01/18/2024 05:57:43 PM

Document Has Been Signed on 01/18/2024 05:57 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SUNSET COAST ASSISTED LIVING 3FACILITY NUMBER:
374604726
ADMINISTRATOR:TAPIA, CHRISTINEFACILITY TYPE:
740
ADDRESS:4886 DOLIVA DRTELEPHONE:
(619) 481-4862
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY: 6CENSUS: 0DATE:
01/18/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Applicant's Representative, Christine TapiaTIME COMPLETED:
06:00 PM
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Licensing Program Analysts (LPAs) Dang Nguyen and Juliana Barfield conducted an announced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. LPAs were greeted by, identified themselves to, and explained the purpose of the visit to the applicant’s representative, Administrator Christine Tapia.

The facility fire clearance was granted on 10/05/2023 and reflected that the facility was approved for six (6) residents in total, of which all may be non-ambulatory, but none may be bedridden. The facility's fire clearance did not include endorsements for delayed-egress doors or secured perimeter, and neither were present during today's visit. The submitted facility sketch was consistent with the current layout of the facility.



During today’s visit, LPAs, accompanied by the applicant’s representative, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets, sinks, and showers were in working order. The facility’s ambient internal temperature was complaint at 72 degrees F. Hot water temperature at taps accessible to residents were also compliant: Kitchen sink was 113 F, Bathroom #1 sink was 110 F, and Bathroom #2 sink was 111 F.

The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food for future resident use. All kitchen appliances were in working order. Kitchen Refrigerator temperature was 40 F, and Kitchen Freezer temperature was 0 F. Staff Refrigerator temperature was 21 F, and Staff Freezer temperature -18 F.

[CONTINUED ON LIC 809-C]
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: SUNSET COAST ASSISTED LIVING 3
FACILITY NUMBER: 374604726
VISIT DATE: 01/18/2024
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[CONTINUED FROM LIC 809]

The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of sharp objects, medication, and confidential resident and staff records.

No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant’s representative, no firearms or ammunition are or will be stored at the facility.

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. Fire extinguishers were serviced within the last twelve months. A complete first aid kit was present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. The applicant passed the pre-licensing inspection.

LPAs also provided the Component III Training during today’s visit. Tapia was advised that the facility’s application is pending management final review and approval.

An exit interview was conducted with the applicant’s representative, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024
LIC809 (FAS) - (06/04)
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