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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006380
Report Date: 01/03/2025
Date Signed: 01/03/2025 10:52:15 AM

Document Has Been Signed on 01/03/2025 10:52 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HPNB RESIDENTIAL CAREFACILITY NUMBER:
306006380
ADMINISTRATOR/
DIRECTOR:		YHLUWALIA, ANAMIKAFACILITY TYPE:
735
ADDRESS:709 S PLYMOUTH PL.TELEPHONE:
(714) 866-9108
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY: 4CENSUS: 3DATE:
01/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Raveena GoreTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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On January 3, 2025 at 8:00am, Licensing Program Analysts (LPAs) Eboni Bentley and Edward Kim made an unannounced required annual inspection at this facility. LPAs Bentley and Kim met with Licensee (LI) Anish Gore and stated the purpose of this visit.
The facility is a two-level structure licensed for four (4) ambulatory clients, age 18 through 59 and offers Adult Residential Care.
LPAs Bentley and Kim conducted a tour of the physical plant accompanied by LI Gore and the following was observed: There were no bodies of water on the premises, all rooms were inspected, beds and bedding supplies were available, lighting was provided in all rooms, and storage for the client's personal belongings were observed in clients’ closets. Additional bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperatures measured temperature range of 140.5 degrees F and 142.5 degrees F. Smoke and carbon monoxide detectors were tested and operational.

All client bedrooms were clean, well-organized, and had all the necessary items and storage space. The kitchen was clean and organized. All knives and sharp objects were locked in a drawer near the sink. Hazardous cleaning chemicals were found in a locked cabinet, under the sink. A two-day supply of perishable food items and seven-day supply of nonperishable food items was observed in the pantry near the stove. A fully charged fire extinguisher was near the pantry with a last service date of December 16, 2024. In the hallway is a locked medication cabinet behind the stairs with medications and resident files.

The garage was clean organized, and walkways were free of clutter and debris. A refrigerator with a supply of perishable items and a washer and dryer were observed to be in working condition. LPA Kim observed a first aid kit with all the required elements. Facility has emergency food and water supply. A review of the Medication and Medication Administration Record (MAR) was conducted, and LPA Kim observed the records are in compliance.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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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Document Has Been Signed on 01/03/2025 10:52 AM - It Cannot Be Edited


Created By: Eboni Bentley On 01/03/2025 at 10:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HPNB RESIDENTIAL CARE
FACILITY NUMBER: 306006380

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on ovservation and interview, the licensee did not comply with the section cited above in two out of two bathrooms, which poses an immediate health, safety or personal rights risk to persons in care. LPA observed Bathroom #1 was measured at 140.5 F and Bathroom #2 measured at 142.5 degrees F.
POC Due Date: 01/04/2025
Plan of Correction
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Licensee will obtain the correct temperature gauge and maintain a temperature log testing temperatures every two hours from 10am on January 3, 2025 to 10am January 4, 2025. Licensee stated they will submit water temperature logs to CCLD via email to eboni.bentley@dss.ca.gov and edward.kim@dss.ca.gov by POC due date January 4, 2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Eboni Bentley
LICENSING EVALUATOR SIGNATURE:
DATE: 01/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/03/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HPNB RESIDENTIAL CARE
FACILITY NUMBER: 306006380
VISIT DATE: 01/03/2025
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The backyard was clean and free of clutter and debris. A shaded patio area with tables and chairs observed.
A review of three (3) clients service files and four (4) staff personnel files revealed to be complete. Facility has liability insurance on file effective February 1, 2024 through February 1, 2025. The facility has the current administrator's certification on file for Anamika Ahluwalia and a pending renewal for Licensee Anish Gore received October 14, 2024.

One deficiency was cited during today’s inspection visit. per Title 22, Div. 6, Chapter 1 of the California Code of Regulations 80088 (e) (1). One Type A Violation was provided as water temperature.

An exit interview conducted and a copy of the report and appeal rights were provided to Licensee Anish Gore.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
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