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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002853
Report Date: 08/26/2024
Date Signed: 08/26/2024 10:48:32 AM


Document Has Been Signed on 08/26/2024 10:48 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:HUNTINGTON ELDER-CARE IIFACILITY NUMBER:
306002853
ADMINISTRATOR:CARMEN G. ACHIMFACILITY TYPE:
740
ADDRESS:9452 NAUTILUS DRIVETELEPHONE:
(714) 378-0563
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 6DATE:
08/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator, Carmen AchimTIME COMPLETED:
11:00 AM
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On 8/26/2024, Licensing Program Analysts (LPAs) Janette Romero and Debbie Palacios conducted an unannounced visit to the facility for a required annual inspection. LPAs met with Administrator, Carmen Achim who was informed of the purpose of the visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents and an approved hospice waiver for three (3), and LPA was informed two (2) residents are currently receiving hospice services at the facility.

During today's visit, LPAs observed two (2) staff and six (6) residents present. LPAs toured the facility with Administrator Achim and observed the facility is made up of a one-story home with six (6) resident bedrooms, eight (8) bathrooms, a staff room, kitchen, dining room, living room, and attached garage. During the tour, Administrator Achim tested one (1) of the smoke alarms/carbon monoxide detectors and LPAs observed it to be operational. LPAs also observed a charged fire extinguisher mounted near the kitchen. Indoor and outdoor passageways were free of obstruction. The facility has outdoor shaded seating for the residents in care. There were no bodies of water observed on the premises. Medications are stored in a cabinet near the laundry service. Resident bedrooms had the required furniture and lighting. Bathrooms had grab bars near the toilet and in the showers. LPAs observed a hallway closet filled with clean linens and towels. The facility had a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Staff present have a criminal record clearance. Resident files reviewed had updated physician's reports and admission agreements. The living room fireplace is adequately screened. Long Term Care Ombudsman information is visibly posted near the kitchen and copies of the facility sketch are posted throughout the facility.

During today's visit, LPAs did not issue any citations. An exit interview was conducted where a copy of this report was reviewed and provided to Administrator Achim.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: 951-248-0350
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2024
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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