<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604454
Report Date: 11/15/2022
Date Signed: 11/15/2022 02:39:22 PM


Document Has Been Signed on 11/15/2022 02:39 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 MANORFACILITY NUMBER:
374604454
ADMINISTRATOR:DERAFERA, TESSFACILITY TYPE:
740
ADDRESS:14755 BUDWIN LNTELEPHONE:
(619) 625-6886
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY:21CENSUS: 21DATE:
11/15/2022
TYPE OF VISIT:Case Management - Licensee InitiatedANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Zayden Chen, LicenseeTIME COMPLETED:
02:09 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) Esther Miller conducted an announced case management visit with Zayden Chen, Licensee, and Tess Derafera, Administrator. Licensee asked for LPA to review updated admissions agreement.

On 11/03/22, LPA received an email from Licensee (zaydenchen@zealseniorliving.com) asking to approve an updated Admissions Agreement. LPA and Licensee met via Teams in order to review sections that were not approved. Items that needed revision included, but was not limited to, elopement, visitation policy, pet policy, house rules, changing resident's rooms, providing locks for residents, and general language of Admissions Agreement. LPA sent Licensee an email with relevant sections of Title 22 discussed during the meeting. Licensee agreed to rewrite and resubmit Admissions Agreement for LPA approval.

An exit interview was conducted, and a copy of this report and Licensee's Rights (9058 01/16) were provided to the Licensee.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1