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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005434
Report Date: 06/03/2022
Date Signed: 06/03/2022 10:56:48 AM


Document Has Been Signed on 06/03/2022 10:56 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: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: 1DATE:
06/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Caregiver, Nilo SanguyoTIME COMPLETED:
11:15 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 and was granted entry into the facility and explained the reason for the visit. Caregiver Nilo Sanguyo contacted Administrator Mark Strauss and house Manager Thomas Duffy regarding visit. Co- Licensee Karen Mahmalji was also present at time of visit.

During the visit LPA toured the facility with staff. Facility is a 6 bedroom (5 Resident rooms 1 staff room) and 2 bathroom single story home. There is 1 Resident in care. LPA observed covid signage and required Department postings. LPA observed copy of Administrators Certificate expiring December 21, 2023. 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. Resident was observed relaxing in bedroom. Facility has operating 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 a secured location for resident medication and files. LPA observed 1 of 1 resident file. Resident's emergency contact info and Physician's report is current. Resident has 30 day supply of medications. Facility has designated visitation area. LPA observed 1 fire extinguisher fully charged and mounted.

An exit interview was conducted with Caregiver Nilo Sanguyo 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: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
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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