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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003898
Report Date: 07/12/2024
Date Signed: 07/15/2024 07:58:27 AM


Document Has Been Signed on 07/15/2024 07:58 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
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, CA



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: 5DATE:
07/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Alexander GabatTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced Required Annual Inspection. The
facility file was reviewed prior to the visit. LPA was welcomed by, identified herself to, and discussed the
purpose of the visit with Administrator Alexander Gabat. According to the facility’s license, the facility has a maximum capacity of six residents, of whom all may be non-ambulatory.

LPA toured the interior and exterior of the facility and inspected each room. The facility was sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and resident activities.

Cooking/dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications labeled and locked as required.

No pool or body of water was present. Water temperature was measured at 113 degrees F. Per Alexander, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present. First aid kit was complete.

Resident records reviewed contained required documentation. Hospice resident full bed rail orders were verified. Staff records reviewed contained required documentation.

No deficiencies were cited on todays date. An exit interview was conducted with Administrator, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2333
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
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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