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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005434
Report Date: 06/20/2022
Date Signed: 06/20/2022 03:10:27 PM


Document Has Been Signed on 06/20/2022 03:10 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: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:
06/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:03 PM
MET WITH:Caregiver Lester DigalTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced Case Management to follow up on Technical Assistance issued on 06/03/2022. LPA Tirre met with Caregiver Lester Digal and stated the purpose of the visit.

At 2:10PM LPA Tirre toured facility’s back yard with caregiver and observed the following items cleaned from last visit on 6/3/2022: Facility cleaned scattered cigarette butts from backyard pots and tables. LPA observed grounds cleared of water puddles and remaining pool water cleared. Water hose was neatly wounded against wall. LPA observed backyard no longer had pile of wood logs. Facility maintained 30 days supply of PPE.

LPA observed other items such as old wheelchair, Old microwave, rug, trash can of shrubbery, mattress, commode, hoyer lift, and swing frame located in a pile on side of garage. Caregiver stated items were scheduled for pick up by disposal service.

Facility requested an extension due to items needing to be picked up. LPA extended Technical Advisory for additional week by June 27, 2022. Administrator to contact LPA regarding Pick up.

LPA Tirre conducted a exit interview with Caregiver Lester Digal and left a copy of report at facility.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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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