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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005586
Report Date: 10/04/2021
Date Signed: 10/05/2021 09:49:45 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:HARBOR SHORES ASSISTED LIVING RCFEFACILITY NUMBER:
306005586
ADMINISTRATOR:SAMUEL, VIOLAFACILITY TYPE:
740
ADDRESS:16621 CAROUSEL LNTELEPHONE:
(714) 717-0806
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92649
CAPACITY:6CENSUS: 0DATE:
10/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Licensee Viola SamuelTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Shobhana Frank conducted an unannounced visit for the purpose of conducting a Required 1 Year inspection. LPA was greeted and granted entry by Licensee Viola Samuel and reason for visit was explained.
LPA tour the facility with Licensee. The facility currently has 0 residents in care. Facility appears clean and sanitary. All resident's rooms had the required elements as well as restrooms stocked with soap/sanitizer. LPA observed the screening/sanitizing station in the entrance of the facility. Facility has COVID precaution postings as well as all required department postings. Facility has completed the Mitigation Plan and is approved. LPA observed adequate emergency food and water supply as well as the First Aid kit which contained all required items. Facility has all required items of PPE on site. LPA toured the outside grounds and observed ample shaded outside visitation area.
Based on the observations made during today’s visit, no deficiencies were noted per Title 22 Division 6 of the California Code of Regulations.
An exit interview was conducted with Licensee and a copy of this report was provided.
SUPERVISOR'S NAME: Marina StanicTELEPHONE: (714) 703-2851
LICENSING EVALUATOR NAME: Shobhana FrankTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
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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