306006005-8-9-2021-22-AS-JTIE-C5QRCK-20210809125427

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006005
Report Date: 08/09/2021
Date Signed: 08/09/2021 12:54:41 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:	OAKMONT OF HUNTINGTON BEACH		FACILITY NUMBER:	306006005
ADMINISTRATOR:	YOUNAN, HEATHER		FACILITY TYPE:	740
ADDRESS:	18922 DELAWARE STREET		TELEPHONE:	(657) 204-4600
CITY:	HUNTINGTON BEACH	STATE: CA	ZIP CODE:	92648
CAPACITY:	111	CENSUS: 76	DATE:	08/09/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Executive Director, Heather Younan		TIME COMPLETED:	01:15 PM

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Licensing Program Analysts (LPA’s) Jenifer Tirre and Kimberly Lyman conducted an announced visit for the purpose of a Pre-Licensing evaluation due to change of ownership. LPA’s Tirre and Lyman were greeted and granted entry to the facility by front desk receptionist and met with Executive Director Heather Younan.

An initial application to operate a Residential Care Facility for the Elderly was submitted to the Central Applications Unit (CAU) on 4/29/2021 for a capacity of 111 residents of which, 103 may be Non-ambulatory residents and 8 residents may be bedridden, with a hospice waiver for 15 residents.

At approximately 9:40 am, LPA’s Tirre and Lyman along with Executive Director Heather Younan commenced the inspection tour. During today's inspection visit, LPA's observed the following:

Structure: Facility is a three story building housing 44 apartments in the assisted living and 32 apartments in the memory care unit. Facility offers a library, beauty salon, media room, gym, several dining areas as well as outside patio areas. Living Room/ Dining Room: Adequate seating is available in the main dining room and visiting areas. Bedrooms Residents: All rooms are equipped with appropriate lighting, chair, night stand and ample closet space. Rooms contain a mini kitchen area complete with a mini fridge. Bathrooms: All resident bathrooms have a working toilet/ wash basin as well as grab bars and non-skid surface in the shower. Emergency Phone Numbers and Exit Plan: Posted in entrance of facility. Food Service: Facility has ample perishable and non perishable food supplies. All equipment is tested for temperature and are within acceptable ranges. LPA observed a posted menu with multiple choices for residents. Smoke Detectors: On 10/29/2020 an annual inspection with Cal Building Systems was done on Carbon monoxide and smoke detectors were tested operational. Smoke detectors are tested in-house semi annually and documentation was provided. Fire extinguishers observed are fully charged. Fire sprinklers are tested by an outside company and facility provided documentation of testing. Toxins: Secured and inaccessible to residents in care. Water Temperature: Tested and recorded between 113 and 122 degrees F in selected tested bathrooms. CONT ON LIC 809C DATED 08/09/2021

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

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: OAKMONT OF HUNTINGTON BEACH	FACILITY NUMBER: 306006005
	VISIT DATE: 08/09/2021

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Emergency Supplies: LPA observed ample emergency food and water stored onsite at facility. LPA's observed the emergency disaster plan posted at front of facility lobby. Medications, First-Aid Kit & Book: LPA observed first aid kits and all contained required elements. Medications are stored in locked medication carts. Facility uses electronic medication administration record. Resident & Staff File: LPA reviewed staff and resident files during the visit. Reading Material, Games, and Equipment: LPA observed the activity room as well as posted activities in multiple locations. Outside areas: LPA observed two different outside shaded areas for residents, both located on first floor. Fire Clearance: Approved for 103 non-ambulatory residents and 8 bedridden residents on 05/19/2021. LPA observed the emergency chair adjacent to the staircase.

Licensee to address the following items:

Please post the 'Let Us Know" Poster along with all required Department postings at entrance of facility
Update Emergency Disaster Plan Names to reflect current Personnel
adjust water temperature to reflect proper temperature below 120 degrees F

No deficiencies found at this time. The facility is ready to be licensed. Component III not conducted during visit due to facility already being fully operational.

An exit interview was conducted with Executive Director and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Jenifer Tirre	TELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021

LIC809 (FAS) - (06/04)

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