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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003798
Report Date: 11/04/2022
Date Signed: 11/04/2022 11:35:41 AM


Document Has Been Signed on 11/04/2022 11:35 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 ELDERCARE IVFACILITY NUMBER:
306003798
ADMINISTRATOR:NICOLAE ACHIMFACILITY TYPE:
740
ADDRESS:9442 NAUTILUS DRIVETELEPHONE:
(714) 962-8230
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 6DATE:
11/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Administrator/Licensee Carmen AchimTIME COMPLETED:
11:50 AM
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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 by Staff and signed in upon entry. LPA explained the reason for the visit.

During the visit LPA toured the facility with Administrator Carmen Achim. Facility is a 7 bedroom,( 6 resident bedrooms 1 staff bedroom) and 8 bathrooms single story home. There are 6 Residents in care. LPA observed proper covid signage near front entrance of facility. Facility has a sign in, sanitization and temperature check station. Facility has required Department postings. Facility has required Emergency Disaster Plan posted. LPA observed Administrator's Certificate expiring 6/19/24. LPA toured all Residents rooms, all rooms where within regulations. Resident rooms had required furnishings such as bed, dresser, night stand and chair. All restrooms observed contained soap, toilet paper, hand towels and hand sanitizer. Common restroom has hand washing signs posted. Residents were observed relaxing inside bedrooms and watching TV in living room. Facility has audible alarms for each door entrance/exit. Facility has 1 fire extinguisher which is mounted and fully charged. Facility has supply of PPE. Facility has 2 refrigerators with ample food supply. LPA observed 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 files. Residents emergency contact information and Physicians reports are current. Facility has several designated visitation areas.


No deficiencies noted during todays visit. An exit interview was conducted with Administrator and a copy of report was left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022
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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