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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005206
Report Date: 12/09/2022
Date Signed: 12/09/2022 10:46:22 AM


Document Has Been Signed on 12/09/2022 10:46 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 & INLAND A/SC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:SOCAL ASSISTED LIVINGFACILITY NUMBER:
306005206
ADMINISTRATOR:CHENG, CHIN-WENFACILITY TYPE:
740
ADDRESS:8132 STERLING DRIVETELEPHONE:
(714) 267-4105
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 6DATE:
12/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:42 AM
MET WITH:Administrator, Megan ChengTIME COMPLETED:
11:00 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 and temperature checked by staff.

During the visit LPA toured the facility with Caregiver. Administrator Megan Cheng arrived during visit. Facility is a 6 bedroom,( 5 resident bedrooms 1 staff bedroom) and 3 bathroom single story home. There are 6 Residents in care. LPA observed proper covid signage at front entrance of facility as well as sign in, sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring September 16, 2023. LPA toured all Residents rooms, all rooms had required furniture such as bed, chair, lamp, dresser and closet space. All restrooms observed contained soap, toilet paper, and paper towels. Restrooms had working toilet and wash basin. Restrooms water temperature tested at 106.7 degrees Fahrenheit. Restrooms had proper hand washing signs posted. Residents were observed relaxing in the Living room watching TV. Facility has operating audible alarms for each sliding door entrance/exit. Facility has 2 fire extinguishers which are mounted and fully charged. Facility has supply of PPE. Facility has refrigerator with ample food supply. LPA observed facility has emergency food and water supply. Facility has required Emergency Disaster Plan posted. Facility has a secured location for resident medication and files. Facility has 30 days supply of medications for clients. LPA reviewed Resident files during visit. Resident emergency contact information and Physicians reports are current. Facility has a designated visitation area. Staff are following Covid-19 guidelines wearing Face Masks.

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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2022
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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