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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003048
Report Date: 09/25/2025
Date Signed: 09/25/2025 12:13:18 PM

Document Has Been Signed on 09/25/2025 12:13 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:HELEN'S GUEST HOMEFACILITY NUMBER:
306003048
ADMINISTRATOR/
DIRECTOR:		LIBERTY VENTURAFACILITY TYPE:
740
ADDRESS:9152 HYDE PARK DRIVETELEPHONE:
(714) 378-0970
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 4CENSUS: 3DATE:
09/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:58 AM
MET WITH:Sarah Levante - House Manager TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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 On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to conduct a required annual. LPA was greeted and granted entry by staff and explained the reason for the visit. Sarah Levante, House Manager, arrived at 9:00 AM.

The facility is a one-story home with four resident bedrooms, two bathrooms, kitchen, dining room, living room, laundry room, staff office, back yard and attached two-car garage.The facility is licensed for 4 bedridden residents and has a hospice waiver for 2 residents. The facility has a current census of 3 residents.

During today’s visit, LPA toured the facility and inspected the physical plant, including but not limited to testing all smoke detectors and water temperatures. The water temperatures tested at 81.5 to 103.6 degrees. All smoke detectors were operational. The facility’s last fire drill was conducted on July 29, 2025. LPA inspected the facility food supply and observed the facility retained a minimum of two days perishable and seven days non-perishable food on hand. LPA observed a secured area for medications in kitchen cabinet. LPA observed emergency food and water in facility garage.



LPA reviewed two out of two staff training and fingerprint records, LPA observed facility did not have the following training including: dementia, postural supports, restricted health conditions and hospice care. LPA conducted a complete review of client records.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Andrea Mendivil
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 09/25/2025 12:13 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 09/25/2025 at 11:20 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: HELEN'S GUEST HOME
FACILITY NUMBER: 306003048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations licensee did not comply with the regulation cited above as the water temperature measured between 81.5 and 103.6, which poses an immediate health and safety risks to persons in care.
POC Due Date: 09/26/2025
Plan of Correction
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Facility agreed to adjust water temperature and provide proof to LPA by POC due date. Faciltiy agreed to weekly temperature logs.
Type A
Section Cited
HSC
1569.625(b)(2)
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed the facility did not comply with the cited above in staff files reviewed as there was no training for dementia, postural supports, restricted health conditions or hospice care. This poses an immediate health and safety risks to persons in care.
POC Due Date: 09/25/2025
Plan of Correction
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Facility agreed to conduct in service trainings of 4 hours of dementia, and 4 hours between the following categories: postural supports, restricted health conditions and hospice care and provide proof to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/25/2025 12:13 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 09/25/2025 at 11:20 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: HELEN'S GUEST HOME
FACILITY NUMBER: 306003048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(1)
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (1) The personal rights of residents specified in Sections 87468.1, Personal Rights of Residents in All Facilities and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities shall be posted as applicable to the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation personal rights were not posted in the facility. This poses a potential personal rights risk to persons in care.
POC Due Date: 10/01/2025
Plan of Correction
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Facility agreed to post a copy of personal rights from 1569.269 in the entrance of the facility and provide proof to LPA by POC due date.
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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HELEN'S GUEST HOME
FACILITY NUMBER: 306003048
VISIT DATE: 09/25/2025
NARRATIVE
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LPA Mendivil consulted with Licensee Peter Ventura via telephone regarding the facility is licensed as a Residential Facility for the Elderly and the importance of following regulations for the correct type of facility.
LPA observed no active administrator certification on record.

Based on observations made deficiencies are being cited per Title 22. A copy of this report and appeal rights were provided to facility representative.
NAME OF LICENSING PROGRAM MANAGER: Alisa Ortiz
NAME OF LICENSING PROGRAM ANALYST: Andrea Mendivil
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/25/2025 12:13 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 09/25/2025 at 11:43 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: HELEN'S GUEST HOME
FACILITY NUMBER: 306003048

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(a)
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section....
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the cited above as the Administrator is listed as Liberty Ventura, who no longer has an active administrator certification. Licensee Peter Ventura is a certified Adult Residential Facility Administrator and does not have an active RCFE administrator certification. This poses an immediate health and safety risk to person in care.
POC Due Date: 09/26/2025
Plan of Correction
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Facility agreed to provide updated administrator with current RCFE administrator certification.
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.
Alisa Ortiz
NAME OF LICENSING PROGRAM MANAGER:
Andrea Mendivil
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2025


LIC809 (FAS) - (06/04)
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