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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003054
Report Date: 09/23/2022
Date Signed: 09/23/2022 03:08:38 PM


Document Has Been Signed on 09/23/2022 03:08 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:PACIFIC HEAVEN RES. CARE FACILITY FOR THE ELDERLYFACILITY NUMBER:
306003054
ADMINISTRATOR:BETTY BURGOSFACILITY TYPE:
740
ADDRESS:16301 MAGELLAN LANETELEPHONE:
(714) 655-6843
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 6DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Administrator, Betty BurgosTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted, granted entry into the facility and explained the reason for the visit.

During the visit LPA toured the facility with Administrator Betty Burgos. Facility is a 5 bedroom,( 4 resident bedrooms 1 Upstairs staff bedroom) and 3 bathrooms two story home. There are 6 Residents in care. LPA observed proper covid signage at front entrance of facility. Facility has required Department postings. LPA toured all Residents rooms, all rooms had required furnishings such as bed, mattress, dresser, night stand and lamp. All restrooms observed contained soap, toilet paper, and towels. Restrooms had proper hand washing signs posted. Residents were observed relaxing in the Living room watching TV, eating lunch at dining table and reading. Facility has 2 fully charged Fire Extinguishers. Facility has supply of PPE goods. Facility has refrigerator and pantry with perishables and non- perishables food supply. Facility has emergency food and water supply. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for Residents. LPA reviewed Residents files during visit. LPA observed 6 of 6 Resident files during visit. Residents emergency contact information and Physicians reports are current. Facility has several designated visitation areas. LPA observed Hallways and walkways free of debris and clutter.

No deficiencies noted during todays visit. An exit interview was conducted with Administrator Betty Burgos and a copy of report and confidential names list was provided to facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2022
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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