374604454-4-25-2024-08-AS-JBAD-D4NRYJ-20240425132625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604454
Report Date: 04/25/2024
Date Signed: 04/25/2024 01:26:29 PM

Document Has Been Signed on 04/25/2024 01:26 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	HUNTINGTON MANOR		FACILITY NUMBER:	374604454
ADMINISTRATOR:	DERAFERA, TESS		FACILITY TYPE:	740
ADDRESS:	14755 BUDWIN LN		TELEPHONE:	(858) 748-3381
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	21	CENSUS: 20	DATE:	04/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Caregiver Hydee Jumulon and Administrator Tess Derafera		TIME COMPLETED:	01:30 PM

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Licensing Program Analyst (LPA) Juliana Barfield conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Haydee Jumulun. Administrator Tess Derarfera arrived shortly after.

According to the facility’s license, the facility has a maximum capacity of twenty-one (21) residents, of whom twenty-one (21) may be non-ambulatory, of which 12 may be bedridden.. During today’s inspection, there were a total of (20) residents in care. This facility does not feature a secured perimeter or delayed egress doors.

LPA, accompanied by Tess Derafera toured the interior and exterior of the facility, and inspected each room. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.

Hot water temperature at taps accessible to clients were all compliant.

There was at least 2 days supply of perishable food, and at least 7 days non-perishable food present. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters observed available to clients. Medications were labeled, as required, and stored in locked areas.

(CONTINUED ON LIC809-C)

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Juliana Barfield	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

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

FACILITY NAME: HUNTINGTON MANOR	FACILITY NUMBER: 374604454
	VISIT DATE: 04/25/2024

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the premises. According to Tess Derafera, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility.

LPA interviewed staff and clients. LPA interviews did not raise any licensing concerns. LPA reviewed multiple staff and client records. Files reviewed contained required documents. Confidential records were stored in locked areas. Tess Derafera presented proof of current/active business liability insurance.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Tess Derafera to whom copies of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Juliana Barfield	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024

LIC809 (FAS) - (06/04)

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