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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601621
Report Date: 03/26/2026
Date Signed: 03/26/2026 12:05:19 PM

Document Has Been Signed on 03/26/2026 12:05 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:246 VAN ZANT HOMEFACILITY NUMBER:
198601621
ADMINISTRATOR/
DIRECTOR:		JACLYN VAN ZANTFACILITY TYPE:
735
ADDRESS:455 E. 246TH PLACETELEPHONE:
(310) 518-3372
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 4CENSUS: 4DATE:
03/26/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:22 AM
MET WITH:Mario Fernandez. TIME VISIT/
INSPECTION COMPLETED:
12:23 PM
NARRATIVE
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On March 26, 2026, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced case management visit at the facility. The Direct Support Provider, Mario Fernandez, greeted LPA Dabuet. The LPA explained to Fernandez that the visit was related to an incident that occurred on February 28, 2026.

On March 2, 2026, the El Segundo Regional Office received an incident report regarding Client #1 (C1), submitted by Harbor Regional Center. The report indicated that (C1) had an unauthorized absence (AWOL) or elopement on February 28, 2026. LPA Dabuet interviewed staff members, Staff #1 and Staff #2, regarding this incident and confirmed that (C1) eloped from the facility without staff supervision during the the day of the incident. (S1), who was present during the incident, provided inconsistent accounts of how the elopement occurred, which differed from the statement provided by Administrator Carlos Chavarria in an email to LPA Dabuet.

During the visit, (C1) was interviewed but was unable to engage in conversation due to (C1's) health condition. A review of (C1's) Client Development and Evaluation Report, dated October 22, 2024, and the 30-Day Behavioral Assessment, dated February 6, 2026, confirmed that (C1) exhibits disruptive social behaviors, including instances of being AWOL and a history of accidents when left unsupervised.

Based on evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of NEGLECT/LACK OF SUPERVISION is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency has been observed, and a citation has been issued (ref. LIC 809-D).

An exit interview was conducted, and Program Director Mario Fernandez provided with a copy of the report and Appeal Rights.
NAME OF LICENSING PROGRAM MANAGER: Janae Hammond
NAME OF LICENSING PROGRAM ANALYST: Ernand Dabuet
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2026
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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Document Has Been Signed on 03/26/2026 12:05 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 03/26/2026 at 11:43 AM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: 246 VAN ZANT HOME
FACILITY NUMBER: 198601621

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/09/2026
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement is not met as evidenced by:
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Licensee is to review Title 22 Regulation Section 80078 and submit a plan to retrain all staff on DSP responsibilities and duties. POC is to be submitted to LPA Dabuet at ernand.dabuet@dss.ca gov by 04/09/26
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Based on interview and record review, Licensee did not ensure to meet the client's needs of care and supervision when (C1) eloped from the facility 02/28/26. The client had a history of distructive behaviors including AWOL and requires constant supervision. This violation poses a potential health and safety risks to clients in care.
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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.
Janae Hammond
NAME OF LICENSING PROGRAM MANAGER:
Ernand Dabuet
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2026


LIC809 (FAS) - (06/04)
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