<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003054
Report Date: 10/14/2024
Date Signed: 10/14/2024 04:45:49 PM


Document Has Been Signed on 10/14/2024 04:45 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: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: 5DATE:
10/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Administrator/Licensee Betty BurgosTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/14/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Administrator Betty Burgos was present to assist with the facility inspection on today's date.

The facility is licensed for six (6) non-ambulatory residents with approved hospice waiver for two (2) residents. Currently, there are Five residents present during visit. There are (0) Hospice residents present during today’s visit.

This is a two story with a two-car garage facility. The facility has four bedrooms (two private resident rooms & two shared rooms), one office and four bathrooms.

At around 2:10PM, LPA conducted a tour of the physical plant accompanied by Administrator Burgos, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.8 degrees F. A comfortable temperature of 74 degrees F. was maintained in the facility.


LPA observed the facility to be furnished at the time of the visit. Storage areas for files and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. A fire extinguisher was charged and mounted. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

CONTINUED ON 809C
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024
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: PACIFIC HEAVEN RES. CARE FACILITY FOR THE ELDERLY
FACILITY NUMBER: 306003054
VISIT DATE: 10/14/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed a working land line phone was operational. The last fire drill was conducted on 10/1/2024. The facility had operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 9/13/2024 - 9/13/2025.

A review of four residents (R1-R4) service files and three staff (S1-S3) personnel files revealed to be complete.

No deficiencies during this inspection visit.

An exit interview was conducted with Administrator/Licensee Burgos, and a copy of the report was provided.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2