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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006110
Report Date: 08/14/2024
Date Signed: 08/14/2024 01:47:32 PM

Document Has Been Signed on 08/14/2024 01:47 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:SELECT SENIOR CARE IIFACILITY NUMBER:
306006110
ADMINISTRATOR/
DIRECTOR:
DATCU, DANIELFACILITY TYPE:
740
ADDRESS:16412 MARK LANETELEPHONE:
(909) 358-1209
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92647
CAPACITY: 6CENSUS: 5DATE:
08/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Administrator, Daniel DatcuTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 8/14/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA was greeted and granted entry by Administrator, Daniel Datcu who was informed of the purpose of LPA's visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents and an approved hospice waiver for four (4). LPA was informed four (4) residents are currently receiving hospice services at the facility. During today's visit, there was five (5) residents and two (2) care staff present.

LPA toured the facility with Administrator Datcu and observed the facility is made up of a one-story home with six (6) resident bedrooms, three (3) bathrooms, one (1) staff room, a kitchen, dining room, living room, and attached garage. During the tour, Administrator Datcu tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed charged fire extinguishers mounted throughout the facility, last serviced on 7/18/2024. Indoor and outdoor passageways were free of obstruction. The facility has outdoor shaded seating for the residents in care. There were no bodies of water observed on the premises. Medications are secured in a locked kitchen cabinet. Resident bedrooms had the required furniture and lighting. Bathrooms had grab bars near the toilet and in the showers. LPA toured the kitchen and observed the facility had more than a 2-day supply of perishable foods and 7-day supply of non-perishable food items. Resident files reviewed had signed admission agreements and residents with a dementia diagnosis had updated physician reports. Staff present have a criminal record clearance and valid first aid/CPR certification. A record review revealed the facility's last fire drill was conducted on 7/20/2024 and earthquake drill on 6/19/2024. LPA toured the garage and observed emergency food, two refrigerators with additional perishable foods, non-perishable food items, incontinent supplies, along with an operable laundry service.

During today's visit, LPA did not observe any issues or concerns. An exit interview was conducted where this report was reviewed and provided to Administrator Datcu.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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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