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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005390
Report Date: 06/09/2020
Date Signed: 06/09/2020 10:38:56 AM

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:AFFINITY HOME CAREFACILITY NUMBER:
306005390
ADMINISTRATOR:GUTIERREZ, CECILIAFACILITY TYPE:
740
ADDRESS:7101 NIMROD DRIVETELEPHONE:
(562) 676-5369
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 6DATE:
06/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Heather Edgington - AdministratorTIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Patricia Velazquez contacted the facility via telephone to conduct a Case Management visit due to the COVID-19 Pandemic and pre-cautionary measures. LPA Velazquez spoke with Administrator Heather Edgington, identified herself and discussed the purpose of today's visit. The purpose of today's Case Management visit was to follow-up on matters that were discovered during the complaint investigation with complaint control number 22-AS-20200323112054.



On today's visit, LPA Velazquez briefly interviewed Administrator Edgington. LPA also provided extensive technical assistance and consultation regarding Criminal Record Clearance, Medical Assessments, and Hospice Care. There were no deficiencies issued during this Case Management visit.



An exit phone interview was conducted with Administrator Heather Edgington and a copy of this report along with the LIC 811 were signed by LPA Patricia Velazquez and sent via email to Administrator Edgington who agrees to sign and date the report. This report was sent via email and an electronic read receipt confirms receiving the report. Administrator Edgington agrees to send the original report by mail to the CCLD Regional Office (RO) in Orange.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Patricia VelazquezTELEPHONE: (714) 380-0440
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2020
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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