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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003898
Report Date: 04/22/2022
Date Signed: 04/22/2022 10:47:56 AM


Document Has Been Signed on 04/22/2022 10:47 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
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: 4DATE:
04/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Alexander Gabat, AdministratorTIME COMPLETED:
11:10 AM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by Administrator. LPA met with Alexander Gabat, Administrator and explained the nature of the visit.

LPA Martinez accompanied by Administrator began the tour of the inside and outside of the facility. There are four residents in care and there are no active covid-19 cases in the facility. LPA upon entry observed three residents in the living room watching TV and remainder of resident in their bedrooms. All residents appeared to be clean and well taken care of. LPA observed a check in station in the main entry of the facility. LPA observed required department postings, covid-19 precautionary postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have a supply of soap and appeared to be clean. LPA inspected residents’ bedrooms and appeared to be clean. All bedrooms observed to have all required components. Residents bedrooms are all private with one resident per. LPA observed the emergency disaster and evacuation plan. Facility has a supply of back-up emergency food and water supply in attached garage. LPA observed facility to have PPE supplies in storage and throughout the facility in all bedrooms as well as common spaces. LPA toured the outside of the facility and observed several shaded seating areas for resident’s enjoyment. LPA observed a staircase in the outside of the house that leads to the upstairs of the facility. There are no residents residing in the second floor of the facility, second floor is inaccessible to residents in care. The facility has completed the LIC808 Mitigation Plan. The plan was reviewed and approved by the Department on December 20, 2021.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
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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