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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002648
Report Date: 08/14/2024
Date Signed: 08/14/2024 12:26:54 PM

Document Has Been Signed on 08/14/2024 12:26 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HUNTINGTON ELDER-CARE IFACILITY NUMBER:
306002648
ADMINISTRATOR/
DIRECTOR:		CARMEN G. ACHIMFACILITY TYPE:
740
ADDRESS:20141 BUSHARD STREETTELEPHONE:
(714) 964-9628
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 5DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Carmen AchimTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 8/14/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with Administrator, Carmen Achim who was informed of the purpose of LPA's visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents. The facility also has an approved hospice waiver for three (3) and LPA was informed three (3) residents are currently receiving hospice services at the facility.

During today's visit, LPA observed Staff 1 (S1), Staff 2 (S2), and five (5) residents present. LPA toured the facility with Administrator Achim and observed the facility is made up of a one-story home with six (6) resident bedrooms, six (6) resident bathrooms, a staff room, kitchen, dining room, living room and attached garage. During the tour, Administrator Achim tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed a charged fire extinguisher mounted in the hallway leading to the facility's backyard. Indoor and outdoor passageways were free of obstruction. The facility has outdoor shaded seating for the residents in care. There were no bodies of water observed on the premises. Medications are secured in a locked cabinet near the visitor's restroom. Resident bedrooms had the required furniture and lighting. Bathrooms had grab bars near the toilet and in the showers. LPA observed a hallway closet filled with clean linens and towels. The facility had a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Resident files reviewed had signed admission agreements and physician reports. Long Term Care Ombudsman and complaint information are posted near the front entrance.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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: HUNTINGTON ELDER-CARE I
FACILITY NUMBER: 306002648
VISIT DATE: 08/14/2024
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LPA attempted to review the personnel records for the S1 and S2 present. Administrator Achim reported the facility does not have personnel records for S1 and S2. Administrator Achim added S1 and S2 had their personnel records in their car and recently had a car accident and no longer have their records. Additionally, interviews and a record review, revealed S1 present has not submitted to a criminal record clearance or obtained an exemption to work in the facility. Administrator Achim added they did not double check to verify S1 possessed a criminal record clearance or exemption prior to working in the facility. S1 was interviewed and reported they have been working in the facility for one (1) week.

During today's visit, LPA issued a deficiency for the lack of personnel records and assessed a civil penalty for S1's lack of criminal record clearance or exemption. An exit interview was conducted where this report was reviewed and provided to Administrator Achim along with a LIC 809-D, LIC421BG, Confidential Names List (LIC 811), and Appeal Rights.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2024 12:26 PM - It Cannot Be Edited


Created By: Janette Romero On 08/14/2024 at 11:53 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HUNTINGTON ELDER-CARE I
FACILITY NUMBER: 306002648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on interview and record review, the licensee did not comply with the section cited above by allowing Staff 1 to work in the facility without obtaining a criminal record clearance/exemption, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2024
Plan of Correction
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During LPA's visit, LPA observed Administrator, Carmen Achim escort Staff 1 out of the facility. Administrator Achim reported they will request for Staff 1 to submit to a fingerprint clearance, should they wish to return to work in the facility. Administrator Achim reported they will wait for the Guardian clearance letter or contact the Orange County Regional Office to ensure Staff 1 has a criminal record clearance/exemption prior to allowing them to return to work in the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tricia Danielson
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/14/2024 12:26 PM - It Cannot Be Edited


Created By: Janette Romero On 08/14/2024 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: HUNTINGTON ELDER-CARE I
FACILITY NUMBER: 306002648

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not have personnel records for Staff 1 and Staff 2 present during LPA's visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/30/2024
Plan of Correction
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Licensee reported they will create personnel records for Staff 1 and Staff 2 and scan copies of the files to LPA via email by close of business on 8/30/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Tricia Danielson
LICENSING EVALUATOR NAME:Janette Romero
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2024


LIC809 (FAS) - (06/04)
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