565850576-1-16-2025-29-AS-TCAA-DCYU2D-20250116141146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850576
Report Date: 01/16/2025
Date Signed: 01/16/2025 02:12:27 PM

Document Has Been Signed on 01/16/2025 02:12 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	COASTAL HAVEN SENIOR LIVING		FACILITY NUMBER:	565850576
ADMINISTRATOR/ DIRECTOR:	NUNAG, IRA MAE		FACILITY TYPE:	740
ADDRESS:	4922 LAFAYETTE STREET		TELEPHONE:	(805) 718-2702
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY: 6		CENSUS: 0	DATE:	01/16/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:05 AM
MET WITH:	Ira Mae Nunag		TIME VISIT/ INSPECTION COMPLETED:	02:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Teresa Camara conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Ira Mae Nunag. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver for four (4) has been requested. LPA reviewed the Component III orientation with applicant. The facility is one story. At 11:10 a.m. a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for six (6) non-ambulatory residents, four (4) of which may be bedridden residents in room numbers 2, 3, 4, and 6. All residents bedrooms are private. Resident bedrooms have beds, nightstands, lighting, clothing storage, chairs, and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket, and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room. There are no staff rooms - awake staff only. All rooms were free of odors. All window screens were clean and maintained in good repair. There are three (3) full bathrooms; two are in the hallway and one is a private bathroom for bedroom 1. The resident bathrooms have showers with non-skid materials. The toilet and shower have grab bars. The hot water temperature was measured at 106.7F - 108F which is within the required range of 105F and 120F. Resident and staff records are stored in a locked cabinet located in the dining room. Medications are centrally stored in a locked cabinet in the dining room. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in a drawer in the kitchen. (continued on page 2, LIC809-C)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COASTAL HAVEN SENIOR LIVING	FACILITY NUMBER: 565850576
	VISIT DATE: 01/16/2025

NARRATIVE

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(continued from page 1, LIC 809)

Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents by removing the knobs when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. There was an insufficient supply of nonperishable food and water. The applicant will purchase the required seven (7) day supply of non-perishable food and three day supply of emergency water and provide evidence to LPA. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located in the secured garage and in a locked cabinet under the sink. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, games and/or activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in passageways to nonprivate bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is a fireplace in the living room. It is screened and there are no tools. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit. There is no central air conditioning at this facility, the licensee understand rooms must be cooled to not exceed 85 degrees Fahrenheit.

The facility combination smoke alarm/carbon monoxide detection system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit.
There are two (2) fire extinguishers throughout the house. They are fully charged and were last inspected 9/6/2024.

(continued on page 3, LIC 809-C)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COASTAL HAVEN SENIOR LIVING	FACILITY NUMBER: 565850576
	VISIT DATE: 01/16/2025

NARRATIVE

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(continued from page 2, LIC 809-C)

The laundry area is located adjacent to the kitchen in an enclosed room with locking doors. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in the garage. Extra incontinence supplies are stored in the hall and garage. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted at front door entry. The emergency telephone numbers are posted at the front door entry along with other required postings.

The exterior passageways were clean and clear of any obstructions. There is a patio area at the back of the house with tables and chairs where residents can sit. There is a shaded area and a separate umbrella for shade. The entire property is fenced. The back and sides of the house are separated from the front yard by gates on either side of the house. The gates were not self-latching. The applicant will install springs on both gates and provide evidence of this to LPA. There are no bodies of water on the premises at the present time.
The garage is not accessible from the house; the doors were locked.

The following items must be corrected prior to licensure. Submit proof of corrections, along with a copy of this report, to LPA Camara, so that your application may be completed. Send photos of the seven (7) days of non-perishable food and three (3) days of water. Send photos of the springs installed on each gate.

This report will be sent to the Centralized Application Bureau (CAB) once all corrections are received. You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2025

LIC809 (FAS) - (06/04)

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