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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604375
Report Date: 10/03/2025
Date Signed: 10/03/2025 07:20:05 PM

Document Has Been Signed on 10/03/2025 07:20 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:HUNTINGTON HOUSEFACILITY NUMBER:
374604375
ADMINISTRATOR/
DIRECTOR:		DERAFERA, TESSFACILITY TYPE:
740
ADDRESS:14805 BUDWIN LANETELEPHONE:
(858) 513-0589
CITY:POWAYSTATE: CAZIP CODE:
92064
CAPACITY: 6CENSUS: 7DATE:
10/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Caregiver Honeylet Castro Verde, Licensee Zayden Chen, and COO Lynn DrummondTIME VISIT/
INSPECTION COMPLETED:
07:35 PM
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Licensing Program Analyst (LPA) Dang Nguyen made an unannounced visit to conduct a Required Annual Inspection. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Honeylet Castro Verde. LPA then met with Licensee Principal Zayden Chen and Chief Operations Officer (COO) Lynn Drummond, who arrived shortly after.

According to the facility’s license, the facility has a maximum capacity for six (6) residents, of whom all may be ambulatory or non-ambulatory, and three (3) may be bedridden. Per LPA observation, LIC602 Physician’s Reports, and staff interviews: During today’s inspection, there were a total of seven (7) residents in care, of whom four (4) were non-ambulatory and three (3) were bedridden. [The issue of the facility currently being over-capacity was already addressed; Licensee was cited/fined for it on 08/26/2025. Licensee’s application requesting an increase in capacity is pending / under review with CCLD.] The facility’s license does not include endorsements for delayed-egress doors or secured perimeters, and none of these were present.

LPA, accompanied by Licensee’s staff, toured the interior and exterior of the facility and inspected all common areas and resident bedrooms. LPA interviewed multiple residents and multiple staff. LPA reviewed care records for all current residents, and personnel records for all active staff.


[CONTINUED ON LIC 809-C, 1 of 2]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2025
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 7
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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HUNTINGTON HOUSE
FACILITY NUMBER: 374604375
VISIT DATE: 10/03/2025
NARRATIVE
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[CONTINUED FROM LIC 809]

The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were working. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities. The facility’s ambient internal temperature was complaint at 73 F. Where tested, hot water temperature at taps accessible to residents were all compliant: Bathroom #1 Sink was 115.5 F, Bathroom #2 Sink was 115.7 F, Bathroom #3 Sink was 113.2 F, Bathroom #4 Sink was 118 F, Bathroom #5 Sink was 118 F, and Bathroom #6 Sink was 117.9 F. Appliances to preserve perishable food were also compliant in temperature. There was at least two (2) days of perishable food, and at least seven (7) days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present.

There were no sharp objects, toxic chemicals/poisons, or open-faced heaters accessible to residents. Medications were labeled, as required, and stored in locked areas. Confidential records were stored in locked areas. Required licensing postings were observed in visible areas of the facility. Carbon monoxide detector, smoke detectors, emergency lighting, and facility telephone were all working. The facility’s fire extinguisher had been serviced within the last twelve (12) months. No fireplace or pools/bodies of water were observed on the premises. Per the Licensee, no firearms or ammunition are kept at the facility. There were reserve supplies of Personal Protective Equipment (PPE), and staff had been trained on PPE within the last (12) months, as required. Licensee presented proof of current business liability insurance.

Licensee is Limited Liability Company (LLC) registered in California. As of today’s visit, the LLC had a “Forfeited” status with the State Franchise Tax Board (FTB). Regulation required Licensee to ensure that its governing body was active and functioning, to assure accountability. [During today's visit, Licensee E-mailed their accountant and instructed them to pay all taxes and/or fees owed to the FTB, which is necessary to bring the LLC back into good standing. Licensee agreed to continue to oversee the matter to completion.]


[CONTINUED ON LIC 809-C, 2 of 2]
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: HUNTINGTON HOUSE
FACILITY NUMBER: 374604375
VISIT DATE: 10/03/2025
NARRATIVE
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[CONTINUED FROM LIC 809-C, 1 of 2]

During a review of care records, LPA observed, and manager interview confirmed: Resident #1 (R1) through Resident #5 (R5) were each diagnosed with Dementia, per their respective physician’s reports, which also said these residents would not be safe to leave the facility without escort. [See LIC811 Confidential Names List for a description of select person identifiers used in this report.] However, Licensee did not ensure that the facility’s exterior exit doors had working staff alert devices installed on them, as required when caring for such residents. Also, Licensee did not have documentation that 4 of 7 residents [R1, R2, R4, and Resident #6 (R6)] received an annual routine visit with their respective licensed medical professional, also known as an annual “physical” or “check-up” (or documentation of the resident and/or responsible person’s refusal), as required.

During a review of personnel records, LPA observed, and manager interview confirmed: 3 of 10 staff [Staff #1 (S1) through Staff #3 (S3)] did not complete the minimum twenty (20) hours of continuing training within the last rolling year, as required. [Regulation requires 20 hours per direct care staff, of which 8 must be on Dementia care and 4 must be related to postural supports, restricted health conditions, and hospice care.] Also, Licensee did not ensure that 2 of 10 staff [Staff #4 (S4) and Staff #5 (S5)] had current training in First Aid from a qualified source, as required.

Five (5) deficiencies were cited per California Code of Regulations, Title 22 (refer to the LIC809-D pages). Plans of Correction were jointly developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding Disaster Drills (refer to the LIC9102-TV page).

An exit interview was conducted with Licensee Principal, Zayden Chen, to whom a copy of this report, the LIC 809-D pages, the LIC9102-TV page, and the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during today’s visit.
NAME OF LICENSING PROGRAM MANAGER: Simon Jacob
NAME OF LICENSING PROGRAM ANALYST: Dang Nguyen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2025
LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 10/09/2025 01:16 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/09/2025 01:13 PM


Created By: Dang Nguyen On 10/03/2025 at 06:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HUNTINGTON HOUSE
FACILITY NUMBER: 374604375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87205(b)
Accountability of Licensee Governing Body
(b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and manager interview, Licensee did not ensure that the limited liability corporation (which owns and operates the facility) remained active and functioning to assure accountability. This posed a potential health and personal rights risk to 7 of 7 residents [R1 through Resident #7 (R7)] in care.
POC Due Date: 11/03/2025
Plan of Correction
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During today's visit, Licensee E-mailed their accountant and instructed them to pay all taxes and/or fees owed to the California Franchise Tax Board, which is necessary to bring the LLC back into good standing. Licensee agreed to continue to oversee the matter to completion, and to send LPA proof that the LLC is active again, by the POC due date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review and manager interview, Licensee did not ensure that 3 of 10 staff (S1, S2, and S3) had completed 20 hours of training within the last year, of which 8 hours were required to be on dementia care and of which 4 hours were required to be on postural supports, restricted health conditions, and hospice care. This posed a potential health and personal rights risk to 7 of 7 residents [R1 through Resident #7 (R7)] in care.
POC Due Date: 11/03/2025
Plan of Correction
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Licensee agreed to have S1, S2, and S3 each complete 20 hours of continuing training (ensuring at least 8 hours are on dementia care and at least 4 hours are on "postural supports, restricted health conditions, and hospice care"). Licensee agreed to clearly document the training, and to send proof of completion to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 10/06/2025 08:51 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/06/2025 08:50 AM


Created By: Dang Nguyen On 10/03/2025 at 06:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HUNTINGTON HOUSE
FACILITY NUMBER: 374604375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)(1)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and manager interview, Licensee did not ensure that 4 of 7 residents (R1, R2, R4, and R6) had documentation of an annual routine visit with a licensed medical professional. This posed a potential health risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
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Licensee agreed to coordinate with the responsible persons (RP) to ensure that R1, R2, R4, and R6 complete their annual routine medical visits. (In cases where the RP refuses the annual visit, Licensee will document such refusal in writing.) Licensee agreed to send proof of completion to LPA, by the POC due date.
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements – General: “(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on records review and manager interview, Licensee did not ensure that 2 of 10 staff (S4 and S5) received appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This posed a potential health risk to 7 of 7 residents in care [R1 through Resident #7 (R7)].
POC Due Date: 11/03/2025
Plan of Correction
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Licensee agreed to coordinate with S4 and S5 to ensure both staff complete the necessary training to renew their 2-year First Aid Cards. Licensee agreed to send copies of S4 and S5’s updated First Aid cards to LPA, by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 10/09/2025 01:16 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/09/2025 01:11 PM


Created By: Dang Nguyen On 10/03/2025 at 06:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: HUNTINGTON HOUSE
FACILITY NUMBER: 374604375

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(d)
87705 Care of Persons with Dementia: “(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement.” This requirement was not met, as evidenced by:
Deficient Practice Statement
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Based on records and interviews, 5 of 7 residents (R1 through R5) were diagnosed with Dementia, but Licensee did not ensure the facility had an auditory device (or similar staff alert feature) on its exterior doors. This posed a potential safety risk to persons in care.
POC Due Date: 11/03/2025
Plan of Correction
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During today’s visit, Licensee began the process of installing door chimes on its exterior exit doors but did not have enough chimes to cover all eight (8) doors. Licensee agreed to procure and install additional devices, and to oversee this project to completion. Licensee agreed to text LPA videos of the eight (8) door chimes in place and working, by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Simon Jacob
NAME OF LICENSING PROGRAM MANAGER:
Dang Nguyen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2025


LIC809 (FAS) - (06/04)
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