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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606861
Report Date: 08/14/2024
Date Signed: 08/14/2024 01:46:04 PM


Document Has Been Signed on 08/14/2024 01:46 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:HUNTINGTON BEACH GUEST HOMEFACILITY NUMBER:
300606861
ADMINISTRATOR:L. MANGURAY, N.& W. URETAFACILITY TYPE:
740
ADDRESS:8392 CRANE CIRCLETELEPHONE:
(714) 536-2375
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 4DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Jamie OcaTIME COMPLETED:
01:55 PM
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA was greeted, granted entry by staff, and explained the reason for the visit before entering the facility.

Around 10:30 am LPA Haley began the tour of the facility with staff. There were four residents present for the visit. Right next to the front door there is a screening station and sign in sheet. Next to the front door is a closet with comforters and board games. All resident bedrooms were clean, organized, and had all the necessary requirements: night stand, chair, lamp, and storage space. Resident bathrooms were clean and organized. Hot water temperature was measured in the range of 105.2 – 105.8 degrees Fahrenheit.

The kitchen was clean and organized. All knives and sharp objects were locked under the sink. All burners on the stove were operational. The facility has a two-day supply of perishable food items and seven-day supply of nonperishable food items.

The garage is used for storage and had clear walkways. There’s a washer and dryer in the locked garage and a supply of hazardous cleaning chemicals. There are additional refrigerators in the garage for the residents, and one for staff with an additional supply of food items. An additional supply of nonperishable items are stored in the garage as well as a supply of fruit. There’s a supply of COVID items, including gloves, gowns, N95 mask, hand sanitizers, and disinfectant sprays for use in a large bucket. Miscellaneous items for the facility including a wheelchair, and a locked filing cabinet for resident and staff files.

The backyard was clean and well organized. Walkways were free of obstruction. There's a table with chairs and a sun shade. There’s a locked storage shed in the backyard with a supply of various facility items. In the lock shed is an emergency supply of food, mattresses, bed frames, walkers, and other items.

Continued on LIC809C

SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HUNTINGTON BEACH GUEST HOME
FACILITY NUMBER: 300606861
VISIT DATE: 08/14/2024
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There were no bodies of water observed. All smoke detectors were tested and are operational. The carbon monoxide detector tested operational. Emergency evacuation drills are conducted quarterly, and the last drill was conducted April 15, 2024. A review of all resident files and medications was conducted, as well as a review of 3 staff files.

No deficiencies are being cited during today’s visit. An exit interview conducted, and a copy of the report was provided.

SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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