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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003048
Report Date: 12/09/2021
Date Signed: 12/09/2021 11:17:29 AM

Document Has Been Signed on 12/09/2021 11:17 AM - 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HELEN'S GUEST HOMEFACILITY NUMBER:
306003048
ADMINISTRATOR:LIBERTY VENTURAFACILITY TYPE:
740
ADDRESS:9152 HYDE PARK DRIVETELEPHONE:
(714) 378-0970
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 4CENSUS: 4DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:42 AM
MET WITH:Administrator, Peter Ventura and House Manager, Sarah LevanteTIME COMPLETED:
11:30 AM
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On this day Licensing Program Analyst's (LPA's) Jenifer Tirre and Kevin Saborit- Guasch conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA's was greeted and was granted entry into the facility by staff. LPA's met with Caregiver Miko Samson and explained the reason for the visit.

During the visit Administrator Peter Ventura and House Manager Sarah Levante arrived. LPA's toured the facility with staff. Facility is a 4 bedroom and 2 bathroom single story home. There are 4 Clients in care. LPA observed proper covid signage inside facility. Facility has required Department postings. LPA toured all clients rooms, rooms where within regulations. All restrooms observed contained soap, toilet paper and paper towels. Restrooms had proper hand washing signs posted. Clients were observed sitting down listening to music in living room.

Facility has supplies of PPE. LPA reminded Administrator importance of Department guidelines of having 30 days supply on hand. Facility has ample food supply. Facility has fully charged fire extinguisher. Facility has entrances/exits with audible alarms. Facility has a secured location for Client medication and files. Facility has 30 days supply of medications for clients. LPA reviewed Clients files during visit. Clients emergency contact information and Physicians orders are current.

An exit interview was conducted with House Manager and copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
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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