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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006475
Report Date: 05/30/2024
Date Signed: 05/30/2024 11:08:27 AM


Document Has Been Signed on 05/30/2024 11:08 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:LOVING CARE OF THE HUNTINGTON BEACHFACILITY NUMBER:
306006475
ADMINISTRATOR:KANASE, VIJAYFACILITY TYPE:
740
ADDRESS:8271 KINER DRIVETELEPHONE:
(562) 234-7657
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY:6CENSUS: 5DATE:
05/30/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Licensee, Vijay KanaseTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Jenifer Tirre visited this facility for the purpose of conducting a Pre-Licensing evaluation. Facility is a single story residential home. LPA along with Administrator/Licensee Vijay Kanase toured facility at 9:00AM and observed the following:

Fire clearance approval was received on 01/30/24. Structure: Facility is a one story, 5 bedroom (4 Residents bedrooms and 1 live in staff bedroom) 3 bathroom house with attached garage and a white exterior. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: All Residents bedrooms meet Licensing requirements. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Facility has adequate supply of linens and towels. Emergency Phone Numbers and Exit Plan: Facility has Emergency Plan posted on wall. Food Service: Facility has 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, as well as emergency food and water supply. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Fire extinguishers are mounted and fully charged. Facility has 2 extinguishers. Facility has audible alarms on all sliding/exit doors. Appliances: Gas Stove, microwave and refrigerator are operational. Toxins: LPA observed toxins secured in laundry storage area.. Water Temperature: Tested and recorded between 119.8 to 123.0 degrees F. in facility bathrooms. Reading Material Games, and Equipment: facility has puzzles, games, and books. Medications, First-Aid Kit & Book: Facility has first aid kit present at the facility. Facility has a secured location for medications and facility files. Backyard: LPA observed the facility perimeter is secured by wall with gate on both sides of facility as required. LPA observed shaded outdoor seating.

Administrator's Certificate observed for Myrna Ebreo expiring July 15, 2025 and Vijay Kanase expiring May 1, 2025.


CONTINUED ON 809C
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: LOVING CARE OF THE HUNTINGTON BEACH
FACILITY NUMBER: 306006475
VISIT DATE: 05/30/2024
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Component III Orientation was waived during this pre-licensing visit due to Administrator presently operating other facilities.


Licensee to address the following corrections by 06/10//2024:
  • Garage door to have secure locked door knob upon entrance
  • Facility to obtain Proper approved First Aid Handbook (Licensee ordered and provided proof of delivery next day)
  • Facility has secured gates on both sides of house but gates need to be self latching per regulations.
  • Outside passageway on right side of house has a plumbing drain that has overflow of water from kitchen area, area is a potential fall risk hazard. Facility to repair drain to no longer have overflow
  • Resident Room 3 needs hole in wall patched & repaired


At this time facility is not ready to be licensed. Licensee to contact LPA when corrections are complete.
An exit interview was conducted with Licensee and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2