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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006114
Report Date: 06/13/2024
Date Signed: 06/13/2024 04:49:13 PM

Document Has Been Signed on 06/13/2024 04:49 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 IIIFACILITY NUMBER:
306006114
ADMINISTRATOR/
DIRECTOR:		DATCU, DANIELFACILITY TYPE:
740
ADDRESS:9542 SAILFISH DRTELEPHONE:
(909) 358-1209
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 6DATE:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Administrator/Licensee Daniel DatcuTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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On 6/13/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Administrator (AD) Daniel Datcu was present to assist with the facility inspection on today's date.

The facility is licensed for six (6) non-ambulatory residents with approved hospice waiver for four (4) residents. Currently, there are two(2) Hospice residents present during today’s visit.

This is a single story with a two-car garage facility. The facility has seven bedrooms, six resident rooms, one caregiver room and four bathrooms.

At around 1:30PM, LPA conducted a tour of the physical plant accompanied by Administrator Datcu, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 105.6 degrees F. A comfortable temperature of 76 degrees F. was maintained in the facility.



LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, toxins and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has two fire extinguishers, mounted and charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

CONT ON 809C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
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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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: SELECT SENIOR CARE III
FACILITY NUMBER: 306006114
VISIT DATE: 06/13/2024
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on March 19, 2024. The facility had operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 3/21/24 - 3/21/25. The facility is current on Community Care Licensing annual dues.

A review of four residents (R1-R4) service files and three staff (S1-S3) personnel files revealed to be complete. The facility has the administrator's certification on file for Daniel Datcu

No deficiencies during this inspection visit.

An exit interview was conducted with Administrator, and a copy of the report was provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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