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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005586
Report Date: 10/14/2021
Date Signed: 10/18/2021 01:42:47 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: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:
10/14/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Licensee Viola Samuel TIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Shobhana Frank conducted a Case Management visit for the purpose to verify facility closure. LPA met with the Licensee Viola Samuel.
LPA toured the facility observed no residents in care. LPA observed the home to be empty and found no evidence the home is operating as a licensed facility. Based on observation, the facility is no longer operating as a licensed facility and is closed as of 10/14.2021. During today’s visit, no deficiencies were noted in areas inspected. The Licensee will surrender the licensee via mail. An exit interview was conducted with Licensee 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: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021
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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