Coastal Haven Senior Living

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 10:15AM. When the LPA arrived, there were two (2) staff and six (6) residents present. The LPA was greeted by staff and informed them of the reason for the visit. Administrator/Licensee is currently unavailable. Facility Designee Amelia (Mae) Davis arrived at 11:34AM and Designee Nino Smith arrived at 11:40AM. Facility Designee authorized facility staff to sign today's report. Entrance interview conducted. File Review: Beginning at 10:34AM, LPA reviewed six (6) resident records for documents including, but not limited to: medical assessment, needs and service appraisal, Admission Agreement, and personal rights. Beginning at 12:20PM, LPA reviewed five (5) staff files for documents including but not limited to: health screening, TB test, staff training records, and fingerprint background clearance. All files reviewed were complete and contained all documents. Beginning at 11:48AM, the LPA, along with Facility Designee conducted a tour of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of six (6) resident bedrooms and three (3) bathrooms. The LPA observed 2 (two) fully charged fire extinguishers last serviced on 09/16/2025. Hardwired combination smoke alarms and carbon monoxide detectors were tested and functioned properly during time of visit. LPA observed all required postings throughout the facility. Bedrooms/Bathrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens Report Continued on LIC 809-C such as sheets, pillowcases, mattress pads, and blankets. There are 3 (three) full bathrooms in the facility; 2 (two) are located in the hall and are designated for shared use, 1 (one) is designated for private resident use. Hot water was measured in both common restrooms and measured within the required range. Common Areas: These included the two (2) living rooms and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility maintained a comfortable temperature throughout the visit. Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Sharp objects are stored in a locked drawer. Cleaning supplies are stored locked under the sink. Laundry Room: The laundry room is locked and contained laundry equipment and cleaning supplies. Surrounding Grounds (Outdoors):The backyard has a covered outdoor area equipped with furniture for resident use. All exits were observed to be clear of hazards. Two (2) Outdoor gates were observed to be functional, however, not self-closing or latching at the time of the visit. At this time, no residents have documented elopement or unsafe wandering behaviors. LPA advised Facility Designee to ensure the gate is self-closing and latching in the event any residents' needs change or residents are admitted that may have unsafe wandering or elopement behaviors. One (1) gate, which is utilized as the emergency exit was observed latched from the exterior during the visit. Both gates had locks nearby, but were not locked at the time of the visit. LPA advised removing the locks to ensure emergency exit pathways are clear at all times. Garage: The garage does not have direct access to the facility and was observed locked at the time of the visit. LPA observed the garage to contain extra supplies, emergency food and water, as well as a couch, which appears to be a staff break area. There is also a locked staff room. LPA inquired with Facility Designee whether the facility had obtained permits for the staff room located in the garage, but Facility Designee was unsure. LPA was unable to reach the Fire Inspector during the visit for permit/fire clearance clarification. Interviews: LPA conducted interviews with three (3) residents and two (2) staff. No immediate concerns were voiced during the visit. No citations issued. Exit interview conducted and a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 4, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Teresa Camara conducted a case management - incident visit regarding a self-reported incident which took place on 5/2/2025 involving staff 1 (S1) and resident 1 (R1). LPA met with administrator Ira Mae Nunag. LPA reviewed and obtained pertinent records starting at 10:40 a.m. At 11:10 a.m. LPA interviewed a visitor. At 11:22 a.m. LPA interviewed administrator. Further investigation is necessary. LPA observed staff 2 (S2) was not associated to the facility. S2 was fingerprinted on 4/10/2025 but has not received their criminal background clearance yet. The administrator stated S2 started working in the facility 4/11/2025. Pursuant to Title 22, California Code of Regulations (CCR) and/or California Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D). Civil penalty issued in the amount of $500. Exit interview was conducted. A copy of the report and Appeal Rights were reviewed and provided.the state’s words, verbatim · CDSS document, May 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.17(c)(1)(A) · Plan of correction due date: May 15, 2025

(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7... prior to employment, residence, or initial presence in a facility.This requirement is not met as evidenced by: Based on observation and record review, the licensee did not comply with the section cited above as S2 did not have a fingerprint background clearance and has been employed since 4/11/2025, which poses an immediate safety and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 15, 2025

Plan of correction: Licensee told S2 they must get fingerprint clearance and associated to the facility before working any further at the facility. Licensee agreed to ensure the error with S2's fingerprints is remedied and Licensee will verify S1's fingerprint clearance and association.

Type of visit: Prelicensing

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 106.7*F - 108*F which is within the required range of 105*F and 120*F. 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) (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) (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.the state’s words, verbatim · CDSS document, Jan 16, 2025

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Method: Telephone call with CAB COMP II Participants: Nunag, Ira Mae On 12/3/24, the applicant/administrator participated in COMP II at CAB via telephone call with analyst at CAB. Identification of the applicant and administrator was verified by confirming driver’s license number. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant and administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Dec 3, 2024