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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604375
Report Date: 03/24/2021
Date Signed: 03/24/2021 05:47:07 PM

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 HOUSEFACILITY NUMBER:
374604375
ADMINISTRATOR:DERAFERA, TESSFACILITY TYPE:
740
ADDRESS:14805 BUDWIN LANETELEPHONE:
(619) 625-6886
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:6CENSUS: 5DATE:
03/24/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Zayden Chen, ApplicantTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Dawn Segura conducted a Pre-Licensing Virtual Visit, via video conference, due to COVID-19, to observe the facility for compliance with Title 22, Division 6, of California Code of Regulations and Health & Safety Code. The LPA was joined on the video call by Zayden Chen, Applicant.

The LPA and applicant toured the physical plant, and LPA observed the following: resident accommodations, including furnishings, linens, and personal hygiene items; resident bathrooms were equipped with grab bars, non-skid mats, and water temperature measured at 110 degrees Fahrenheit in a bathroom designated for use by residents; resident and staff records were located in a locked office; food service space, including dishes, utensils, refrigerators, freezers, and adequate food storage and preparation space are present; cleaning and potentially toxic substances are stored in the laundry room in a locked cabinet; a locked cabinet and locked drawers are available for storage of medication; a first aid kit and first aid manual are present; activities, supplies and sufficient space in which to conduct activities are present; a fire extinguisher was present; smoke and carbon monoxide detectors are present and were recently inspected and determined to be operable by fire safety inspector; required facility postings are present and visible in a common area of the facility. According to applicant, there are no guns, weapons, or ammunition present or that will be stored on the facility property. A water fountain on the premises was observed to be surrounded by a fence with a locked gate. The foregoing items reviewed during the visit are in compliance with Title 22, Division 6, Chapter 8, of California Code of Regulations.

The administrator’s certification for Tess Derafera expires on November 13, 2022.

Component III was conducted and completed following the pre-licensing physical inspection.

Approval of the application is pending receipt of an updated STD 850 Fire Safety Inspection Request to approve retention of bedridden residents. Additionally, the Emergency Disaster Plan needs to include fire safety precautions specific to evacuation of bedridden residents in the event of an emergency or disaster.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021
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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HUNTINGTON HOUSE
FACILITY NUMBER: 374604375
VISIT DATE: 03/24/2021
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The applicant was advised that the application is pending management final review and approval. A copy of this report and Applicant Rights (LIC 9058) were provided to Zayden Chen via electronic mail. An electronic mail read receipt confirmation was requested to be sent to the LPA upon receipt of the documents.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619)767-2329
LICENSING EVALUATOR NAME: Dawn SeguraTELEPHONE: (619) 417-3928
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021
LIC809 (FAS) - (06/04)
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