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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005396
Report Date: 09/28/2022
Date Signed: 09/28/2022 12:51:03 PM

Document Has Been Signed on 09/28/2022 12:51 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:PACE RECOVERY CENTER LLCFACILITY NUMBER:
306005396
ADMINISTRATOR:WILLIAM SANCHEZFACILITY TYPE:
772
ADDRESS:211 22ND STTELEPHONE:
(213) 924-6442
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92648
CAPACITY: 6CENSUS: 4DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Compliance Officer Shahan Suzemeyan and Director of Mental Health Samantha MeyerTIME COMPLETED:
01:00 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
Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required infection control annual visit. LPA was greeted, granted entry into the facility by Staff and explained the reason for the visit.

During the visit LPA Tirre toured the facility with Compliance Officer Shahan Suzemeyan and Director of Mental Health Samantha Meyer. Facility is a 3 bedroom and 4 bathrooms three story home. There are 4 Clients in care. LPA observed facility has required Department postings visible to the public and residents. Upon entry of facility a guest sign in station. LPA toured all Clients rooms, all rooms appeared clean and within regulations. Rooms had required furnishings such as bed, dresser, night stand and lamp. Restrooms observed contained working wash basin, soap, toilet paper, and paper towels. Clients were observed relaxing in the Living rooms and bedrooms. Facility has operating smoke detectors and carbon monoxide detectors. Facility has 3 fire extinguishers which are fully charged.

Facility has supply of PPE. Facility has refrigerator and pantry with ample food supply. LPA observed facility has emergency food and water supply. Facility has two-day supply of Perishable and seven-day supply of non-perishable foods available as required by regulations. Facility has Evacuation Plan and Personal Rights posted. Facility has a secured location for client medication and files. Facility has 30 days supply of medications for clients. LPA reviewed 4 of 4 clients files during visit. Clients emergency contact information and Physicians reports are current. Facility has designated visitation area.

No deficiencies noted during today’s visit. An exit interview was conducted with Compliance Officer. During exit interview LPA Tirre advised Compliance Officer that Program Plan may require updates. LPA will follow up at a later time. A copy of report along with a confidential names list was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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 1