La Costa Residence

Type of visit: Required - 1 Year

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for six non-ambulatory residents. Facility has an approved hospice waiver for six residents and the home currently has three residents. Administrator (AD) Restituto Calilung arrived shortly to conduct facility tour. AD provided updated liability insurance that expires on 4/3/2026. LPA along with AD toured the facility at 1:05 PM. LPA toured the physical plant, checked food service, and facility documentation. The home consists of six resident bedrooms, living room, dining room, kitchen, three bathrooms and an attached garage along with an ADU for staff. The facility recently when through a remodel to add 2 bedrooms. Licensee is in process of applying for a new fire clearance to accommodate the 2 bedrooms. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. At 1:10PM, LPA observed bleach under the sink in the bathroom across bedroom 1 unsecured and accessible to residents. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 116.3 degrees F and 117.5 degrees F in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPA reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts quarterly emergency drills with the last drill conducted on 10/5/2025. Continued on LIC809-C dated 1/28/26 Outside grounds were toured. Walkways around the home were clear of hazards. Exit gates is unlocked and operational. LPA observed the emergency food and water supply. First aid kit contained all required items including tweezers, scissors and thermometer. LPA reviewed three resident files and one staff file. All resident files contained required documentation including admission agreements, physician reports, and resident appraisals. Staff file reviewed did not contain evidence of 20 hour of required annual training nor current first aid certification. LPA reviewed medication storage and administration. Medications are stored in a locked closet. Medications are being administered per physician order. Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the licensee and a copy was provided along with appeal rights.the state’s words, verbatim · CDSS document, Jan 28, 2026

The state marks this report as 7 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On this day, Licensing Program Analysts (LPAs) Kevin Saborit-Guasch and Hanna Gough made an unannounced visit to the facility to conduct the required annual inspection. LPAs were greeted and granted entry by facility caregiving staff after introducing themselves and stating the purpose of the visit. Facility manager Bene Therese Molintas was notified by telephone and arrived later to assist with the visit. There are currently four residents in care, two of which are receiving hospice care. LPAs observed residents relaxing in their respective bedrooms. LPAs accompanied by facility staff toured the physical plant. The facility is a one-story house with an attached garage. The facility has five bedrooms including a shared room along with two bathrooms accessed in the hallway and a third en-suite bath attached to the shared room. Additional staff dwelling are in an Additional Dwelling Unit in the backyard. Bedrooms appeared clean and sanitary. Full bed rails present in one bedroom and half rails for two other residents, orders and hospice plans of care reviewed. LPAs observed all the resident bedrooms have the required furnishings. Bathrooms appear clean and sanitary. Bathrooms are equipped with grab bars and slip mats. Hot water temperature measured at 120 and 123F during the visit and was adjusted down. LPAs observed the kitchen has a minimum two (2) day perishable and seven (7) day non-perishable food supply. Sharp items are stored in a secure drawer. Fire extinguishers are charged and mounted. LPAs tested the smoke and carbon monoxide detectors which were found to be operational. The centrally stored medication is located in a locked closet in the hallway. The attached garage is inaccessible to residents and is used for storage and laundry. Cleaning supplies are stored securely in the garage. LPAs and facility staff toured the outside of the facility. LPAs observed an shaded outdoor seating areas with furniture for resident use. The perimeter gates on one side of the property is self-latching, but is locked via a padlock. Citation issued. CONTINUED ON FORM LIC809-C CONTINUED FROM FORM LIC809 LPAs reviewed four resident records which included all necessary components. One admission agreement is for a different licensed location also operated by the licensee. Consultation provided. LPAs reviewed resident medication records and prescription orders for all four residents, no discrepancies observed. LPAs reviewed three staff records which were found to be complete. Training and CPR/First aid training reviewed and up-to-date. All staff are background cleared and associated to the licensed location accurately. Based on the observations made during today’s visit, one type B deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. Four consultations provided on attached Advisory Notes form. An exit interview was conducted and a copy of this report along with appeal rights were provided to a facility representative.the state’s words, verbatim · CDSS document, Jan 3, 2025

The state marks this report as 7 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Prelicensing

Licensing Program Analyst (LPA) Ruth Martinez conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA arrived at the facility was greeted and granted entry by Restituto Calilung, Applicant/Administrator. An initial application to operate an Adult Residential Facility for the Elderly, age 60 years and over, for (6) capacity, (0) ambulatory, (5) non-ambulatory, and (1) bedridden residents was submitted to CCL on 11/06/2023. Structure: The facility is a one-story house with an attached garage with 5 resident bedrooms, 3 full bathrooms, a living room, and a kitchen/dinning. The resident’s bedrooms are spacious and will easily accommodate the resident’s furnishings. There is a large back yard with an exit walkway on one side of the house with covered seating for the residents. Air/Heating: Central air/heating system installed with a central panel to control entire house.Bedrooms Residents: Bedrooms will accommodate 6 residents, bedrooms #5 is designated as the bedridden and has a full bathroom. Bedrooms Staff: No bedroom designated for awake-staff. Bathrooms: All bathrooms have a working toilet, wash basin, walk in shower. Linens & Hygiene Supplies: Adequate supply of linen stored in bedroom hallway storage.Emergency Phone Numbers, Exit Plan & Menu: Posted & readily available for review an emergency disaster plan with means of exiting and emergency phone numbers listed. Menus posted and available. Menus prepared one week prior and listed for food serve for one week. Food Service: Adequate supply of 7-day non-perishable and 2-day perishables are stored in the kitchen. Smoke Detectors: Smoke detectors and carbon monoxide alert systems are hardwired, were tested and found operational. Appliances: Gas five-burner stove, single oven, 2 Continued on LIC809-C refrigerators, microwave, washer, and dryer are clean and noted to be operational. Toxins: All and any toxic chemicals, cleaning solutions and disinfectants are inaccessible to residents are stored and locked in garage. Water Temperature: Tested and recorded maintained at a comfortable temperature and the water temperature measures 120.4 Fahrenheit degrees in facility bathrooms. Medications, First-Aid Kit & Book: Medication and first aid kit/book are stored and locked in a storage closet located in hallway to bedrooms. Resident & Staff Files: Records will be kept locked in a cabinet located in office space. Reading Material, Games, Equipment & Materials: The facility has board games, books, and other recreational materials for the residents use, commensurate with the plan of operation. Fire clearance: Was approved on 12/11/2023.Component III: Component three waived during visit. Applicant is Licensee/Administrator of other licensed facilities. Applicant was reminded that it is required to notify LPA, within 5 business days of admitting the first client. This notification may be done by phone, email or fax. The applicant has met all pre-licensing requirements. LPA will submit notification to CAB in Sacramento for final review prior to license being issued. Exit interview was conducted and a copy of this report was left with the applicant.the state’s words, verbatim · CDSS document, Jan 24, 2024