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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004265
Report Date: 06/02/2021
Date Signed: 06/10/2021 10:02:33 AM

Document Has Been Signed on 06/10/2021 10:02 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:CARING PARTNERS IIFACILITY NUMBER:
306004265
ADMINISTRATOR:PRONDA, EDSYLFACILITY TYPE:
740
ADDRESS:20082 PORT CIRCLETELEPHONE:
(657) 301-2481
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 5DATE:
06/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Licensee, Arlene FajardoTIME COMPLETED:
12:37 PM
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Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted, temperature was checked, and was granted entry into the facility by Licensee Arlene Fajardo and explained the reason for the visit.

During the visit LPA toured the facility. Facility is a 5 bedroom and 2 bathroom single story home. There are 5 Residents in care. LPA observed proper covid signage at front entrance of facility as well as sanitization and temperature check station. Facility has required Department postings. LPA observed copy of Administrators Certificate expiring June 18, 2021. LPA toured all Residents rooms, all rooms where within regulations. All restrooms observed contained soap, toilet paper and paper towels. Restrooms had proper hand washing signs posted. Residents were observed relaxing in the Living room watching TV. Facility has smoke detectors and audible alarms for each sliding door entrance/exit. Facility has 1 fire extinguishers which is out of code and last updated 01/16/2019. Facility has adequate supply of PPE. Facility has 2 refrigerators with ample food supply. LPA observed facility has emergency food and water supply. Facility water temperature was at 105.2 degrees F. Facility has required Emergency Disaster Plan posted. Facility has a secured location for resident medication and files.

Based on the observations made during the visit, an immediate $500 civil penalty for Fire Clearance Violation cited per Title 22 of the California Code of Regulations. This report was discussed with the facility representative. An exit interview was conducted with Licensee Arlene Fajardo and a copy of report along with appeal rights was provided to facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 06/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/02/2021
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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Document Has Been Signed on 06/10/2021 10:02 AM - It Cannot Be Edited


Created By: Jenifer Tirre On 06/02/2021 at 11:30 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: CARING PARTNERS II
FACILITY NUMBER: 306004265

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202


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 section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2021
Plan of Correction
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An immediate $500 civil penalty was cited on this day for Fire Clearence violation. Fire Extinguisher needs to be up to code. Licensee to call Fire department to make appointment by 6/3/21. Fire Extinguisher needs to be corrected by 6/9/21.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2021


LIC809 (FAS) - (06/04)
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