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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003898
Report Date: 02/02/2022
Date Signed: 02/02/2022 11:18:52 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VIA TERCERO HOMESFACILITY NUMBER:
306003898
ADMINISTRATOR:ALEXANDER D. GABATFACILITY TYPE:
740
ADDRESS:22645 VIA TERCEROTELEPHONE:
(949) 305-7357
CITY:MISSION VIEJOSTATE: CAZIP CODE:
92691
CAPACITY:6CENSUS: 0DATE:
02/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Alexander Gabat TIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Albert Marin made an unannounced visit to conduct a case management. LPA met with Administrator (AD) Alexander Gabat and stated the purpose of the visit.

On December 20, 2021, The Community Care Licensing Division (CCLD) Orange Office received an information from AD Gabat that he is planning to suspend the operation of the facility. AD discussed the reasons with the LPA assigned to the facility. The LPA did a consultation with AD on issuance of 30 day notice to all residents, and requested copies of the notice to be provided to CCLD. On January 24, 2022, LPA Marin received information from AD on the placement status of the residents. All residents were relocated to another licensed facility by January 28, 2022. On February 2, 2022, LPA Marin confirmed the placement of residents in other licensed facilities.

For this visit, LPA Marin toured the interior and exterior portions of the facility and did not observe any residents in care. LPA discussed that although the facility is suspending its operation, the facility is expected to pay the annual dues on time, and to comply with ongoing and all regulatory requirements. AD agreed to notify CCLD of plans when to resume the operation and before admitting new residents in the facility.

LPA Marin conducted an exit interview with AD Gabat; and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
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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