306005884-2-11-2021-22-AS-JTIE-BY5TFW-20210211134212

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005884
Report Date: 02/11/2021
Date Signed: 02/11/2021 01:42:19 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:	LUXURY LIVING SENIOR CARE HUNTINGTON BEACH		FACILITY NUMBER:	306005884
ADMINISTRATOR:	LE, TIN		FACILITY TYPE:	740
ADDRESS:	7261 SUNBREEZE DR.		TELEPHONE:	(714) 600-7083
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92647
CAPACITY:	6	CENSUS: 0	DATE:	02/11/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Licensee Ban Nguyen, Administrator Tin Le		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jenifer Tirre contacted the facility via telephone to conduct a pre-licensing visit via Face Time due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the purpose of the call with Administrator Tin Le. An initial application to operate a Residential Facility for the Elderly was received by CCL on 09/22/2020 for a capacity of 6 non-ambulatory residents. There are 0 residents in care during today's visit. LPA Tirre along with Administrator Le and Licensee Nguyen toured the facility via Face Time at 9:30 AM and observed the following: Structure: Facility is a two story, 7 bedroom, 2 bathroom house with an attached garage. The exterior of the house was tan with white trim and has a enclosed patio entrance with small white exit gate which is unlocked and self latching. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All rooms are equipped with appropriate lighting, chair, night stand, and ample closet space. All exit doors are equipped with operational auditory exit alarms. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower. Linens & Hygiene Supplies: Linen supply is in ample supply for residents in care. Emergency Phone Numbers and Exit Plan: Available for review in the Living room entrance area of the facility. Food Service: Facility has a supply of 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator. LPA observed the emergency food and water supply stored in closet entering the garage. Smoke Detectors: Smoke detectors/ carbon monoxide detector were tested operational during today's visit. Fire extinguisher is mounted and charged. Appliances: Stove, oven, refrigerator, microwave, dishwasher, washer, and dryer are clean and operational. Toxins: Locked/stored in secured cabinet under kitchen sink. Water Temperature: Tested and recorded between 109.4 and 113.0 degrees F. in facility bathrooms. CONT ON LIC 809C DATED 2/11/2021

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LUXURY LIVING SENIOR CARE HUNTINGTON BEACH	FACILITY NUMBER: 306005884
	VISIT DATE: 02/11/2021

NARRATIVE

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Medications, First-Aid Kit & Book: First aid kit observed contained all required items. LPA observed completed emergency disaster plan. Medication storage is available and locked in the dinning room of facility. No medications available due to no residents in facility at this time. Resident & Staff File: Records will be locked in a cabinet in dinning room area. No files at this time due to no residents. Reading Material, Games, and Equipment: LPA observed games, puzzles, and books. Facility has an activity calendar with monthly activities posted. Backyard: LPA observed a clean backyard with ample shaded seating. Fire Clearance: Approved for 6 non-ambulatory residents on 11/16/2020.

LPA observed a storage closet that was missing a locked door knob handle. Facility administrator to repair door knob and forward proof to LPA.
LPA observed a old large TV and a wooden board on side of house which is to be thrown out with trash delivery on Tuesday. Administrator to provide proof of area cleared.

The facility is ready to be licensed. A Component III was waived during this visit due to Licensee operating other facilities in orange county.

An exit interview was conducted with Administrator Le via Face Time and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

LIC809 (FAS) - (06/04)

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