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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604095
Report Date: 10/27/2023
Date Signed: 10/27/2023 01:07:49 PM

Document Has Been Signed on 10/27/2023 01:07 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HUNTINGTON CHATEAUFACILITY NUMBER:
374604095
ADMINISTRATOR:DERAFERA, LYNDON M.FACILITY TYPE:
740
ADDRESS:14934 HUNTINGTON GATE DRTELEPHONE:
(858) 231-4126
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 4DATE:
10/27/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Licensee Philip ButzenTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management - annual continuation visit. LPA was greeted by, identified herself to, and explained the purpose of the visit to Licensee Philip Butzen.

During today's visit, LPA observed residents in care and toured the facility LPA reviewed multiple resident and staff records. Each resident record was complete and contained a signed admission agreement, updated physician’s report and medical assessment, documents regarding safeguarding personal property, and personal rights. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. The facility’s water temperature was measured at 105.3 degrees Fahrenheit in non-private bathroom and 106.5 degrees Fahrenheit in a private resident bathroom. LPA provided the Licensee with technical assistance regarding the facility's emergency disaster plan and the Infection Control plan. The Licensee will submit a copy of their current liability insurance to the Department.

No deficiencies were cited on today’s date. An exit interview was conducted with Licensee Philip Butzen, whose signature below confirms receipt of a copy of this report, two LIC9102TA forms, and the Licensee Appeal Rights (LIC9058 01/16).
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Rebecca A Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
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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