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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005434
Report Date: 06/29/2021
Date Signed: 06/29/2021 03:02:00 PM

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:SENIOR ASSISTED CARE HOMESFACILITY NUMBER:
306005434
ADMINISTRATOR:MARK STRAUSSFACILITY TYPE:
740
ADDRESS:15311 CASCADE LANETELEPHONE:
(818) 631-3474
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: 2DATE:
06/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Caregiver, Kristen HammondTIME COMPLETED:
03:15 PM
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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, temperature was checked, and was granted entry into the facility by Caregiver Kristen Hammond and explained the reason for the visit. Caregiver contacted house Manager Thomas Duffy regarding visit,

During the visit LPA toured the facility. Facility is a 5 bedroom and 2 bathroom single story home. There are 2 Residents in care. LPA observed proper covid signage at front entrance of facility as well as sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring December 11, 2021. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper and towels. Restrooms had hand washing signs posted. Residents were observed relaxing in the Living room watching TV and relaxing in bedroom. Facility has smoke detectors and audible alarms. Facility has supply of PPE, however Caregiver was reminded that it is recommended facility has 30 days supply on hand. Facility has required Emergency Disaster Plan posted. Facility has a secured location for resident medication and files. LPA observed 3 months of Medications for Residents.

An exit interview was conducted with Caregiver Kristen Hammond and a copy of this 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: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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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