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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191600341
Report Date: 09/14/2022
Date Signed: 10/07/2022 11:52:42 AM


Document Has Been Signed on 10/07/2022 11:52 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/07/2022 10:14 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

NARRATIVE
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This report is amended to rescind citation # 87305(a)(b), type B violation, and to replace it with 87303(a), type A violation of Title 22.

On 10/7/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiency visit observed during an unrelated complaint visit. LPA called and spoke with Administrator Heather Argueta to conduct a risk assessment. The facility has no Covid-19 cases for the last 14 days. LPA met with Medroom Supervisor Nina Rejuso.

During the visit on 9/14/2022, LPA Montoya observed three men are working in the circular entrance area of the facility; a ladder extended up to the second floor level was observed; wall papers and door paints were scraped off; wall paper and paint debris were observed on the edges of the floor. LPA did not observe any site dust screen or coverings in the job site to protect residents from debris, dust or any particles that may cause risk to residents’ health and safety; LPA observed electrical cord/cable hazards in the hallway to residents’ bedrooms. LPA observed red and white electrical cords off the wall, hanging loosely and accessible to residents. No safeguard was in place in the worksite.

Deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22.

Exit interview conducted and appeal rights discussed. A copy of this report and appeal rights were provided to Medroom Supervisor Nina Rejuso. .


SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
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 2


Document Has Been Signed on 10/07/2022 11:55 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/07/2022 10:16 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: HUNTINGTON RETIREMENT HOTEL
FACILITY NUMBER: 191600341

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/19/2022
Section Cited

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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
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During the visit, LPA observed three men are working in the circular entrance area of the facility; a ladder extended up to the second floor level was observed; wall papers and door paints were scraped off; wall paper and paint debris were observed on the edges of the floor. LPA did not observe any site dust screen or coverings in the job site to protect residents from debris, dust or any particles that may cause risk to residents’ health and safety; LPA observed electrical cord/cable hazards in the hallway to residents’ bedrooms. LPA observed red and white electrical cords off the wall, hanging loosely and accessible to residents. No safeguard was in place in the worksite. This poses an immediate risk to residents’ health, safety and/or personal rights.
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This report is amended to rescind citation # 87305(a)(b), type B violation, and to replace it with 87303(a), type A violation of Title 22.

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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: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2