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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006455
Report Date: 04/26/2024
Date Signed: 04/26/2024 10:51:49 AM

Document Has Been Signed on 04/26/2024 10:51 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
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:
04/26/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:17 AM
MET WITH:Administrator/Licensee Ali NaghibiTIME VISIT/
INSPECTION COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Jenifer Tirre made an announced inspection visit to follow up on corrections identified during Pre Licensing visit on 04/12/2024. LPA identified themselves and discussed the purpose of the visit with Licensee Ali Naghibi. 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 Tirre observed the following:

At 9:30 AM, LPA toured the facility and observed the following:
  • Facility has repaired towel rack in Resident restroom 5
  • Grab bar mounted inside resident restroom 5
  • Facility has posted the "Let Us No" poster in correct regulation size near entrance
  • Toxins in garage are secured inside storage cabinets
  • Spring on perimeter gate has been repaired
  • Alarm on living room sliding door is operational
  • Caregiver room has a secure lock
  • Land line phone is operational



All noted items from visit on 04/12/2024 have been addressed.
The facility is ready to be licensed.


Exit interview 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: 04/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2024
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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