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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006455
Report Date: 04/12/2024
Date Signed: 04/12/2024 12:43:36 PM

Document Has Been Signed on 04/12/2024 12:43 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:HUNTINGTON BEACH VILLAFACILITY NUMBER:
306006455
ADMINISTRATOR/
DIRECTOR:		NAGHIBI, ALIFACILITY TYPE:
740
ADDRESS:18422 MANITOBA LANETELEPHONE:
(714) 322-1910
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92648
CAPACITY: 6CENSUS: 6DATE:
04/12/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:37 AM
MET WITH:Administrator, Ali NaghlbliTIME VISIT/
INSPECTION COMPLETED:
01:00 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 Analysts (LPA's) Jenifer Tirre and Edward Kim made an announced pre-licensing visit. LPA's identified themselves and discussed the purpose of the visit with Administrator Ali Naghlbli. An initial application to operate a Residential Facility Care for the Elderly was submitted to CCL on 8/1/2023. There are 6 residents in care during today's visit. LPA's observed facility is following infection control policies.

LPA's Tirre and Kim along with Administrator Naghlbli toured the facility at 9:00 AM and observed the following:
Structure: Facility is a single story residential home with seven bedrooms (six resident rooms, one caregiver room). Facility has attached garage. Living Room/ Dining Room: Adequate seating is available in the main living room. Bedrooms Residents: All rooms are equipped with appropriate lighting, chair, night stand, dresser and ample closet space. Bathrooms: All resident bathrooms have a working toilet/ wash basin. Facility has Seven restrooms. Six of seven restrooms have grab bars and non-skid surface in the shower. Emergency Phone Numbers and Exit Plan: Posted in facility. Food Service: Facility has ample perishable and non perishable food supplies. All equipment is tested for temperature and are within acceptable ranges. LPA observed a posted menu with multiple choices for residents. Smoke Detectors: Carbon monoxide detectors and Smoke detectors were tested operational. Fire extinguishers are fully charged, mounted and inspected October 10, 2023. Toxins: located in garage in an unsecured location. Water Temperature: Tested and recorded between 105.2 and 109.5 degrees F in tested bathrooms.

Emergency Supplies: LPA’s observed ample emergency food and water stored on site in facility storage.

LPA'S observed the emergency disaster plan and facility has submitted Infection control plan. Medications, First-Aid Kit & Book: LPA’s observed first aid kits and contained required elements. Medications are stored in locked medication cabinet.

CONTINUED ON 809C

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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 2
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: HUNTINGTON BEACH VILLA
FACILITY NUMBER: 306006455
VISIT DATE: 04/12/2024
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
Resident & Staff File: LPA’s reviewed staff and resident files during the visit. Reading Material, Games, and Equipment: LPA ‘s observed facility has Books, games and puzzles in multiple locations. Outside areas: LPA's observed outside shaded area for residents. Fire Clearance: Approved for 5 non-ambulatory residents and 1 bedridden resident on 2/26/24.

Licensee to address the following corrections by 4/22/24:

· The towel rack in Bedroom 5’s restroom needs to be repaired properly and repair holes on wall
· Grab bar in Bedroom 5 restroom needs to be replaced
· Let Us Know Poster is not regulation size, please have proper size poster 20x26 posted near entrance
· Toxins in garage to be secured inside storage cabinet
· Spring on perimeter gate needs to be repaired
· Alarm on living room sliding door needs new batteries
· Caregiver room needs to have lock due to dementia resident in care
· Land line phone needs to be operational

The facility is not ready to be licensed. Licensee to contact LPA when corrections are complete.

Due to time constraints Component III was not conducted today and will be conducted on follow up visit.
An exit interview was conducted with Licensee and a copy of this report was left at the facility.


SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2