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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006657
Report Date: 05/12/2025
Date Signed: 05/12/2025 10:41:02 AM

Document Has Been Signed on 05/12/2025 10:41 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:CK COMMUNITY CAREFACILITY NUMBER:
306006657
ADMINISTRATOR/
DIRECTOR:		TRAN, EVANFACILITY TYPE:
740
ADDRESS:21322 ANTIGUA LANETELEPHONE:
(714) 819-0629
CITY:HUNTINGTON BEACHSTATE: CAZIP CODE:
92646
CAPACITY: 6CENSUS: 0DATE:
05/12/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Administrator Evan TranTIME VISIT/
INSPECTION COMPLETED:
10:55 AM
NARRATIVE
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On May 12, 2025 at 8:45 AM, Licensing Program Analyst (LPA) Brandon Lopez made an announced visit to the facility to conduct the pre licensing inspection. LPA was greeted and granted entry into the facility by Administrator (AD) Even Tran. LPA observed that Evan Tran has a valid Administrator certificate which expires January 2, 2026.

An initial application to operate a Residential Care Facility for the Elderly (RCFE) for a capacity of six (6) non-ambulatory residents, one of which can be bedridden in bedroom four, and has a hospice waiver for six, was received by Community Care Licensing (CCL) on November 18, 2024. This is an initial application with no residents in care. The facility received an approved Fire Clearance by the Huntington Beach Fire Department Inspector Christopher Bird on March 7, 2025.

The facility is a single story home with four resident bedrooms, two of which are shared, two shared resident bathrooms, a living room, a dining room, a kitchen, a sun room, a laundry room, and an attached two car garage. On today's visit, LPA accompanied by the AD conducted a tour of the interior portions of the facility. LPA inspected the four resident bedrooms and observed them to be free of hazards. LPA observed resident bedrooms to have beds and lamps. LPA observed chairs missing in all four resident bedrooms. LPA observed the chest of drawers to be missing in bedroom three. LPA observed resident beds to have clean mattresses, linens, and blankets. LPA observed additional linens to be stored in a hallway closet. LPA inspected the two shared resident bathrooms and observed them to be free of hazards. Resident bathrooms were equipped with grab bars and nonskid floor mats. Faucets and toilets were operational. Hot water temperature measured between 116 to 116.9 degrees Fahrenheit. LPA observed a light bulb missing in bathroom two. CONTINUED ON 809-C
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: CK COMMUNITY CARE
FACILITY NUMBER: 306006657
VISIT DATE: 05/12/2025
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LPA observed kitchen appliances such as the refrigerator, the dishwasher, and the microwave to be clean and operational. LPA observed that one out of the four burners on the gas stove was not operational. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPA observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink. LPA observed a fire extinguisher in the kitchen and in the two car garage. Fire extinguishers charged and serviced as December 6, 2024. LPA tested the wired smoke detectors which tested operational. LPA tested the individual carbon monoxide detectors which tested operational. LPA observed the fire place in the living room to not be in operation at time of visit. LPA observed activity materials such as books, games, and coloring books, and a piano to be stored in the living room. LPA observed that staff files and resident files will be kept in a storage cabinet in the living room. LPA observed the facility did not have a dedicated internet device for resident use. Per the AD, the centrally stored medication will be kept in a locked closet by the dining room. LPA observed the facility has a three day emergency food and water supply stored in the closet. LPA observed chemicals and toxins to be stored in a locked cabinet in the laundry room. LPA observed the door leading to the attached two car garage to be kept locked. LPA observed the two car garage to be used for storage.

LPA, accompanied by the AD, conducted a tour of the exterior portion of the facility. LPA observed construction materials to be in the passageway on the southside of the facility. LPA observed a shaded outdoor seating area with furniture for resident use. The perimeter of the facility are self-latching can be opened in an evacuation. There are no bodies of water on the premises.

LPA advised AD of the following corrections that need to be made:
  • Purchasing chairs for all four resident bedrooms
  • Purchasing a chest of drawers for bedroom three
  • Purchasing and hanging the See Something, Say Something poster (PUB 475) by the entryway
  • Installing a new light bulb for bathroom two
  • Removing the construction materials from the passageway on the southside of the facility
  • Repairing the burner of the gas stove that currently does not work
  • Purchasing an internet device for resident use

Component III was not completed on today's visit and will be conducted on the subsequent visit. An exit interview was conducted with Administrator Evan Tran and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Sheila Santos
NAME OF LICENSING PROGRAM ANALYST: Brandon Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
LIC809 (FAS) - (06/04)
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