374604095-10-19-2023-08-AS-RARZ-CWS23T-20231019170253

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604095
Report Date: 10/19/2023
Date Signed: 10/19/2023 05:02:59 PM

Document Has Been Signed on 10/19/2023 05:02 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	HUNTINGTON CHATEAU		FACILITY NUMBER:	374604095
ADMINISTRATOR:	DERAFERA, LYNDON M.		FACILITY TYPE:	740
ADDRESS:	14934 HUNTINGTON GATE DR		TELEPHONE:	(858) 231-4126
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	6	CENSUS: 4	DATE:	10/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Licensee Philip Butzen		TIME COMPLETED:	05:10 PM

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) Rebecca Ruiz conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Licensee Philip Butzen. The facility is licensed for a maximum capacity of 6 residents, all of which may be bedridden. The facility has a waiver for 6 hospice residents. During today’s visit, the facility had a census of 4 residents, 2 of which were bedridden and receiving hospice services, 1 was non-ambulatory, and 1 was ambulatory. The facility does not have a clearance for delayed egress or secured perimeter and LPA did not observe any aspects of delayed egress or secured perimeter. The Administrator for the facility is Lyndon Derafera and their certificate was valid and current. During today’s visit, LPA toured the facility and inspected each room of the facility, including resident rooms, bathrooms for resident and staff use, kitchen, garage, common areas, and outside space. The facility has a swimming pool on the premises that is located down a flight of stairs. During today's visit, LPA observed two sections of the fence surrounding the pool had been removed, resulting in the swimming pool being unsecured. Per the Licensee, the fence had been removed approximately 3 months ago. A deficiency and an immediate civil penalty of $500 was assessed during today's visit. According to the Licensee, no firearms or weapons are stored on the premises. The facility was found to be clean, safe, and in good repair with no pathway obstructions. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. Continued on LIC809-C page...

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HUNTINGTON CHATEAU	FACILITY NUMBER: 374604095
	VISIT DATE: 10/19/2023

NARRATIVE

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LPA observed a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. LPA observed linens and hygiene products provided to the residents that are in good repair and sufficient to meet their needs. Staff present at the facility during the time of the inspection had a criminal background clearance.

Due to time constraints, the LPA was unable to complete the Required-1 year inspection during today's visit and an annual continuation will be conducted at a later date.

The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC809-D page. The $500 civil penalty was noted on the LIC421IM form.

An exit interview was conducted with Licensee Philip Butzen, whose signature below confirms receipt of a copy of this report, the LIC421IM, and the Licensee Appeal Rights (LIC9058 01/16).

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 10/19/2023 05:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HUNTINGTON CHATEAU	FACILITY NUMBER: 374604095
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87307(e)

(e) Facilities providing services to residents who have physical or mental disabilities shall assure the inaccessibility of fishponds, wading pools, hot tubs, swimming pools, or similar bodies of water, when not in active use by residents, through fencing, covering or other means. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the regulation cited above due to the removal of sections of the fencing surrounding the pool which poses an immediate safety risk to 2 of 4 residents in care.
	POC Due Date: 10/19/2023
	Plan of Correction
1 2 3 4	Prior to LPA leaving the facility, the Licensee reinstalled the sections of the fencing surrounding the pool and ensured that the pool was no longer accessible to residents. POC CLEARED DURING THE VISIT.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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