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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001463
Report Date: 04/15/2022
Date Signed: 04/15/2022 01:24:49 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/15/2022 01:24 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:LIBERTY HOMEFACILITY NUMBER:
306001463
ADMINISTRATOR:LIBERTY VENTURA/PETER VENTFACILITY TYPE:
740
ADDRESS:9892 EFFINGHAM DRIVETELEPHONE:
(714) 965-1545
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 0DATE:
04/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:TIME COMPLETED:
01:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jessica Cho made an unannounced visit at 11:55 AM to conduct the required annual inspection (mitigation). LPA rang the doorbell and knocked on the door but the door was unanswered. LPA Cho contacted the phone number of the Licensee/Administrator (AD) listed on the profile: (714) 965-1545 but was unable to reach the licensee and leave a voicemail. LPA confirmed looking through the window of the facility which appeared vacant with construction work taking place. During the writing of the report, LPA observed a truck pull up in the driveway. LPA entered the facility approximately at 12:43 PM and met with construction worker, Arturo (last name unknown). Arturo contacted AD Liberty Ventura and spoke to licensee on the phone.

AD stated by phone that there are no residents living at the facility since August 2021 and that facility is under renovation. AD confirmed to keep the license active. LPA advised AD that annual fees are currently past due with a balance of $742.00. AD stated that fees will be paid by 04/22/2022.

AD arrived at 12:55 PM and an Advisory Note (LIC9102) was issued during the visit and the LPA will follow-up with the corrections. LPA reminded AD to contact licensing before accepting residents so that the Department can conduct a visit prior to opening. An exit interview was conducted with the AD and a copy of the report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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