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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
306004796
Report Date:
06/15/2022
Date Signed:
06/15/2022 10:28:25 AM
Document Has Been Signed on
06/15/2022 10:28 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 TERRACE
FACILITY NUMBER:
306004796
ADMINISTRATOR:
GREGORY CASE
FACILITY TYPE:
740
ADDRESS:
18800 FLORIDA ST
TELEPHONE:
(714) 848-8811
CITY:
HUNTING BEACH
STATE:
CA
ZIP CODE:
92648
CAPACITY:
185
CENSUS:
139
DATE:
06/15/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:54 AM
MET WITH:
Administrator, Zehra Syed
TIME COMPLETED:
10:35 AM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre made an unannounced visit to facility and discussed purpose of visit with Administrator Zehra Syed.
LPA Tirre visited facility for the purpose of serving Amended Report from complaint investigation Control number 22-AS-20210602084614.
Amended Report was left at facility and exit interview was conducted with Administrator. A copy of this report was left with facility.
SUPERVISOR'S NAME:
Alisa Ortiz
TELEPHONE:
(714) 703-2855
LICENSING EVALUATOR NAME:
Jenifer Tirre
TELEPHONE:
(714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE:
06/15/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/15/2022
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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