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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005884
Report Date: 02/21/2025
Date Signed: 02/21/2025 05:24:36 PM

Document Has Been Signed on 02/21/2025 05:24 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:LUXURY LIVING SENIOR CARE HUNTINGTON BEACHFACILITY NUMBER:
306005884
ADMINISTRATOR/
DIRECTOR:		LE, TINFACILITY TYPE:
740
ADDRESS:7261 SUNBREEZE DR.TELEPHONE:
(714) 600-7083
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6CENSUS: 6DATE:
02/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Caregiver- Agafe LorzanoTIME VISIT/
INSPECTION COMPLETED:
05:40 PM
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
Licensing Program Analyst (LPA) Nancy Guillen made an unannounced visit for the purpose of conducting a required annual Inspection. LPA was greeted and granted entry by caregiver Agafe Lorzano after explaining the purpose of the visit. Administrator was notified via telephone, but was unable to attend. LPA observed the Administrator certificate expired November 28,2024; a deficiency was cited on today’s date. This is a Residential Care Facility for the Elderly (RCFE) licensed to six non-ambulatory residents with a hospice waiver for five. The facility is a two story home. The first floor is made up of five resident bedrooms, two bathrooms, and an attached garage. The second floor contains 3 rooms and a bathroom that are not for resident use.

During the inspection, LPA and caregiver Agafe conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

LPA observed residents watching television and resting in their respective bedrooms. LPA observed six residents in care and three staff present. LPA observed the See Something Say Something Poster (PUB 475) mounted on the wall by the entrance. All resident bedrooms had the required furnishings, however toxins were observed in a residents room; a deficiency is being cited on today’s date. LPA observed all resident beds had linens and blankets with additional linens stored in the hallway closet. LPA observed bathrooms were clean and equipped with grab bars and non skid floor mats. LPA observed all windows were appropriately screened. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested between 108.5 and 112 degrees Fahrenheit. LPA toured the outside of the facility and observed outdoor emergency exit was obstructed; a deficiency was cited on today’s date. LPA observed the backyard had a shaded sitting area with furniture for resident use.

LIC809C

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Nancy Guillen
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2025
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 5
Document Has Been Signed on 02/21/2025 05:24 PM - It Cannot Be Edited


Created By: Nancy Guillen On 02/21/2025 at 04:21 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: LUXURY LIVING SENIOR CARE HUNTINGTON BEACH
FACILITY NUMBER: 306005884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having a staff member sleep in the garage which poses a fire safety risk.
POC Due Date: 02/22/2025
Plan of Correction
1
2
3
4
Caregiver stated they will immediately remove bed and furnishings and send a picture to LPA by POC date.
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having emergency exit obstructed which poses an immediate safety risk to persons in care.
POC Due Date: 02/22/2025
Plan of Correction
1
2
3
4
Caregiver stated the trash bins will be found a different permanent location. In the meantime the trash cans were moved during the annual inspection and cleared POC.
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:Armando J Lucero
LICENSING EVALUATOR NAME:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/21/2025 05:24 PM - It Cannot Be Edited


Created By: Nancy Guillen On 02/21/2025 at 04:21 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: LUXURY LIVING SENIOR CARE HUNTINGTON BEACH
FACILITY NUMBER: 306005884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above due to toxins being accesible to residents which were found in resdient's room which poses an immediate health risk to persons in care.
POC Due Date: 02/22/2025
Plan of Correction
1
2
3
4
Caregiver immediately removed the Lysol in residents room. In-service training to be completed by staff and submitted to LPA via email by February 25,2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Armando J Lucero
LICENSING EVALUATOR NAME:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/21/2025 05:24 PM - It Cannot Be Edited


Created By: Nancy Guillen On 02/21/2025 at 04:21 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: LUXURY LIVING SENIOR CARE HUNTINGTON BEACH
FACILITY NUMBER: 306005884

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above due to administrator's certificate being expired which poses a potential health, safety or personal rights risk to persons in care. LPA verified on DSS website that there was no pending renewal for license and was not listed with an active status
POC Due Date: 03/07/2025
Plan of Correction
1
2
3
4
Licensee stated license is active. Licensee to submit proof of active status or renewal submission to LPA via email by POC date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(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
1
2
3
4
Based on record review and staff interviews, the licensee did not comply with the section cited above in three out of three staff who did not have any annual trainings which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/17/2025
Plan of Correction
1
2
3
4
Caregiver stated annual trainings will be completed and sent to LPA by POC 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.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:Nancy Guillen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: LUXURY LIVING SENIOR CARE HUNTINGTON BEACH
FACILITY NUMBER: 306005884
VISIT DATE: 02/21/2025
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
LPA observed the facility had a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to fully charged and operational. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Toxic chemicals, cleaning solutions, and disinfectants were observed to be locked in the garage and inaccessible to residents. While touring the garage LPA observed a section of the garage to be used as a bedroom; a deficiency was cited on today’s date. Medication cabinet was observed to be locked and centrally stored in the kitchen area. LPA observed the First Aid Kit had all the required components.

LPA began review of the records. LPA Guillen reviewed six resident records. All the required documentation were present and current in the residents’ files reviewed. LPA reviewed three employee records. All employee’s present have a criminal record clearance and were associated to the facility. LPA observed records reviewed have a current First Aid certificate, however no trainings were documented. Per staff interview, no yearly training have been conducted; a deficiency was cited on today’s date.



Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Nancy Guillen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5