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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002648
Report Date: 08/25/2022
Date Signed: 08/25/2022 11:53:14 AM


Document Has Been Signed on 08/25/2022 11:53 AM - 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:HUNTINGTON ELDER-CARE IFACILITY NUMBER:
306002648
ADMINISTRATOR:CARMEN G. ACHIMFACILITY TYPE:
740
ADDRESS:20141 BUSHARD STREETTELEPHONE:
(714) 964-9628
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 6DATE:
08/25/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator, Carmen AchimTIME COMPLETED:
12:15 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced case management visit in conjunction with complaint visit 22-AS-20220824143608. LPA was granted entry by staff. LPA identified themselves and discussed purpose of the visit with Administrator Carmen Achim.

Upon entry into the facility, LPA observed Staff 1 (S1) Mopping floor. Staff 2 came from another room and greeted LPA. S1 and S2 stated they were new staff at the facility. Administrator Carmen Achim arrived shortly after LPA's arrival. LPA Tirre confirmed through Guardian Website that both S1 and S2 does not have criminal record clearance.

During the visit LPA toured the facility, observed bedrooms, kitchen, and living room. Facility has 6 Residents in care. Facility appeared clean and in good condition. At time of visit LPA observed 3 residents (R1, R2, R3) sleeping in bedrooms. LPA observed other three residents (R4, R5, and R6) relaxing in recliners, alert and smiling. R4, R5, and R6 all verbalized that they are well and like it at facility. All residents appeared neatly groomed and content.


Based on the observations made during today's visit, the following violations are being cited per California Code of Regulations Title 22.

An exit interview was conducted and a copy of this report along with appeal rights were left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
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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Document Has Been Signed on 08/25/2022 11:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: HUNTINGTON ELDER-CARE I
FACILITY NUMBER: 306002648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2022
Section Cited

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All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department..This requirement is not being met as evidenced by:
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Based on observation and interview, Licensee failed to ensure S1 and S2 has criminal record clearance before working in the facility. This poses an immediate health and safety risk to residents in care. CIVIL PENALTY ASSESSED.
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
LIC809 (FAS) - (06/04)
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