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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604726
Report Date: 02/20/2025
Date Signed: 02/21/2025 08:49:30 AM

Document Has Been Signed on 02/21/2025 08:49 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:SUNSET COAST ASSISTED LIVING 3FACILITY NUMBER:
374604726
ADMINISTRATOR/
DIRECTOR:		TAPIA, CHRISTINEFACILITY TYPE:
740
ADDRESS:4886 DOLIVA DRTELEPHONE:
(619) 481-4862
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY: 6CENSUS: 5DATE:
02/20/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Caregiver Samantha RiveroTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sabel Martinez conducted an announced Annual Continuation visit. The LPA inroduced himself to Caregiver Samantha Rivero. The facility was licensed for a capacity of six (6) non-ambulatory residents. The facility also had an approved hospice waiver for six (6).

During today's visit. the LPA reviewed facility records, including but not limited to, the facility's Plan of Operation, Infection Control Plan, and Emergency disaster plan. The LPA confirmed the facility had an active liability insurance on file. Required licensing posting were observed in visible areas of the facility.

Review of records revealed the facility did not document emergency drills, and that several staff records were not kept at the facility. Additionally, review of records and interviews revealed Resident # 1 (R1) was bedridden and the facility did not have an approved fire clearance for bedridden residents. A five hundred dollar ($500) immediate civil penalty was assessed for the fire clearance violation. These deficiencies were cited in an LIC 809D form and a plan of correction was jointly formulated with Caregiver Samantha Rivero.

An exit interview was conducted with Samantha Rivero. A copy of this report, LIC 809D, LIC 811, and the Licensee/Appeal Rights (LIC9058), were emailed to Administrator Christine Tapia.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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 02/21/2025 08:49 AM - It Cannot Be Edited


Created By: Sabel Martinez On 02/20/2025 at 10:53 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUNSET COAST ASSISTED LIVING 3
FACILITY NUMBER: 374604726

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2025
Section Cited
HSC
1569.695(c)

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1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement was not met as evidenced by:
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Caregiver agreed to review emegency drill policy, conduct an emegency drill with all staff and submit proof to the LPA by 3/20/25.
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Based on review of records, the licensee did not ensure quarterly drills were conducted, nor documented, which posed a pontential health, safety and personal rights risk to 5 of 5 residents in care.
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Type B
02/20/2025
Section Cited
CCR87412(f)

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87412 Personnel Records (f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement was not met as evidenced by:
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Caregiver agreed to submit personnel records for S1, S2, and S3, to LPA by 3/20/25. The records include the LIC 501, LIC 503, LIC 508, Background clearance letters, and first aid and CPR certificates.
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Based on review of records, the licensee did not ensure personnel records were kept at the facility, which posed a potential health, safety and personal rights risk to 5 of 5 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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Sabel Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/21/2025 08:49 AM - It Cannot Be Edited


Created By: Sabel Martinez On 02/20/2025 at 11:55 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
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: SUNSET COAST ASSISTED LIVING 3
FACILITY NUMBER: 374604726

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2025
Section Cited
CCR
87202(a)(2)

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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. (2) Bedridden persons

This requirement was not met as evidenced by:
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Caregiver agreed to provide R1 an eviction notice, or submitting an LIC 200 requesting bedridden change, to the Department by 2/21/2025.
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Based on review of medical assessment and interviews, the licensee did not ensure the facility had an approved fire clearance for a bedridden resident (R1), which posed an immediate health, safety, and personal rights risk to 1 of 5 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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Sabel Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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