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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005884
Report Date: 03/03/2022
Date Signed: 03/03/2022 02:51:23 PM


Document Has Been Signed on 03/03/2022 02:51 PM - 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:LUXURY LIVING SENIOR CARE HUNTINGTON BEACHFACILITY NUMBER:
306005884
ADMINISTRATOR:LE, TINFACILITY TYPE:
740
ADDRESS:7261 SUNBREEZE DR.TELEPHONE:
(714) 600-7083
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY:6CENSUS: DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit in order to conduct a required annual inspection. LPA arrived at facility, was greeted and granted entry by caregiving staff after explaining the purpose of the visit. Staff called Licensee Ban Nguyen who arrived at approximately 2:00pm.
At approximately 2:05pm, LPA accompanied by Licensee began the tour of the facility. There are currently six (6) residents in care, including two (2) on hospice. Residents are observed relaxing in their bedrooms or in the common areas and appears well taken care of. Facility appears to be clean, sanitary and free of odors in all areas inspected. Each bedroom is observed to have all required components and bathrooms are equipped with grab bars and slip mats.
LPA observed a check-in station next to the entrance of the facility where temperature checks are being documented for visitors. LPA observed the facility has COVID-19 Precautions posters, all required department postings and hand washing signs posted throughout. LPA observed a sufficient supply of food and water. A 30-day supply of medication is stored and locked. Facility has an adequate supply of PPE in the attached garage. LPA toured the outside of the facility. Outdoor space is free of debris and well-maintained with a self-latching gate that can easily be opened. There are no bodies of water on the premises.
During the inspection, LPA observed the following: Facility has unsecured insecticide spray and fertilizer on a shelf in the backyard in the backyard. Large containers of laundry detergent are not locked away in the attached garage. The magnetic lock for the sharps drawer is present but not operational. A Technical Assistance Advisory has been created in regards to these observations.
The facility has completed and submitted their LIC808 Mitigation Plan on 07/26/2021.

Based on the observations made during today’s visit, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
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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