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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005641
Report Date: 05/31/2022
Date Signed: 05/31/2022 11:24:10 AM


Document Has Been Signed on 05/31/2022 11:24 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: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: 2DATE:
05/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Administrator, Myrna EbreoTIME COMPLETED:
11:35 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, asked to do a temperature check, sign in and granted entry into the facility by staff. LPA explained the reason for the visit.

During the visit, LPA toured facility with Administrator Myrna Ebreo. Facility is a 5 bedroom (4 resident rooms, 1 staff room) and 3 bathroom single story home. There are 2 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, 2023. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained working wash basin, soap, sanitizer, toilet paper and paper towels. LPA observed an outside visitation area with ample shading and seating. Residents were observed relaxing in living room watching TV. Facility has audible alarm system for sliding doors, entrances/exits. Facility has 2 fire extinguishers that are fully charged and mounted. Facility has 2 refrigerators and 1 freezer with ample food supply. Facility has required Emergency Disaster Plan posted. LPA observed emergency food and water supply. Facility has a secured location for toxins and hazardous supplies. Facility has a secured location for resident medications and files. LPA observed 2 of 2 resident files. Facility files had updated Emergency Identification and Physician's reports. LPA observed 30 day PPE supply.


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: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2022
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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