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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005641
Report Date: 06/02/2021
Date Signed: 06/10/2021 09:58:59 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:HUNTINGTON BEACH HOME CAREFACILITY NUMBER:
306005641
ADMINISTRATOR:EBREO, MYRNAFACILITY TYPE:
740
ADDRESS:8271 KINER DRTELEPHONE:
(714) 843-9384
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 4DATE:
06/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Administrator, Myrna EbreoTIME COMPLETED:
03:49 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, asked to do a temperature check, sign in and granted entry into the facility by Caregiver Lynville Galleros and explained the reason for the visit. Administrator Myrna Ebreo arrived during the visit.

During the visit, LPA toured facility with Administrator Myrna Ebreo. Facility is a 5 bedroom 3 bathroom single story home. There are 4 Residents in care. LPA observed proper covid signs at front entrance of facility as well as temperature/ guest check in and sanitization station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring July 15, 2021. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper and paper towels. LPA observed an outside visitation area with ample shading and seating. Residents were observed relaxing in their bedrooms. Facility has audible alarm system. Facility has 2 fire extinguishers that are updated as of 11/5/2020. Facility has 2 refrigerators and 1 freezer with ample food supply. Facility water temperature was at 105.4 degrees F. Facility has required Emergency Disaster Plan posted. LPA observed food and water supply. Facility has a secured location for resident medications and files.

During the visit, LPA consulted with Administrator regarding the importance of maintaining a thirty day supply of PPE on site. Facility has less than 30 days supply of PPE.

No deficiencies noted during todays visit. An exit interview was conducted with Administrator Myrna Ebreo 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: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021
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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