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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003048
Report Date: 11/29/2022
Date Signed: 11/29/2022 11:36:33 AM

Document Has Been Signed on 11/29/2022 11:36 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:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Sarah Levante, House ManagerTIME COMPLETED:
11:35 AM
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
 On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a Required Annual Inspection. LPA Quiroz was greeted and granted entry into the facility by Caregiver 1 (CG1) and met with House Manager (HM) Sarah Levante.

This facility is a Residential Care Facility for the Elderly licensed to provide services to four (4) Bedridden residents and has a hospice waiver for (2) two residents. Facility is currently providing hospice services to zero (0)residents at this time. Administrator Peter Ventura has an Administrator Certificate with expiration date of 9/24/2023.

During today's visit, LPA Quiroz reviewed 4 of 4 resident records. On or about 10:43am LPA Quiroz along with (HM )Levante toured the interior and exterior of the facility. There are four (4) residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed Resident 1 and Resident 2 in the living room area listening to music with staff supervision. Facility staff indicated Resident 3 and Resident 4 are currently at their Day Program and return back to facility between 1:30pm-3:00pm. Two of four residents present in the facility appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected resident's bedrooms and appeared clean and sanitary. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. (HM) Levante indicated facility is taking temperatures three times daily; and documenting results.

LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food, water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed ample seating area with table and chairs for client's enjoyment in backyard area.

CONTINUED ON NEXT PAGE...

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 306003048
VISIT DATE: 11/29/2022
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
26
27
28
29
30
31
32
CONTINUED...The facility has completed the LIC 808 Mitigation plan dated 5/25/2021. The LIC 808 Mitigation Plan was reviewed and approved by LPA Quiroz during today's visit.

During today's inspection visit, LPA Quiroz provided California Code of Regulations Title 22 consultation and COVID-19 guidelines. (HM) Levante indicated "All staff and residents are fully vaccinated for COVID-19, received first booster, second booster and flu vaccine already."

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with (HM) Levante, and a copy of this report and LIC 811s-Confidential Names were provided at exit.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2