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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004454
Report Date: 03/12/2024
Date Signed: 03/12/2024 02:38:40 PM


Document Has Been Signed on 03/12/2024 02:38 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:NS CAREFACILITY NUMBER:
306004454
ADMINISTRATOR:NOVAC SOFRONIFACILITY TYPE:
740
ADDRESS:10431 AVENIDA CINCO DE MAYOTELEPHONE:
(714) 599-3531
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:6CENSUS: 6DATE:
03/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Novac Sofroni, Licensee/AdministratorTIME COMPLETED:
02:40 PM
NARRATIVE
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit in conjunction to a 10 day inspection visit for complaint control #22-AS-20240311085256.
LPA Quiroz met with Licensee/Administrator (L/AD) Novac Sofroni and explained the reason for the visit.
During today's visit, LPA Quiroz along with (L/AD) Sofroni conducted a tour of the interior and exterior of facility premises. At 1:02pm, while conducting facility tour in garage area, LPA Quiroz was not able to walk through garage area due to clutter. (L/AD) Sofroni verified indicating "Yeah, I know I need to clean this garage. It's bad." (SEE LIC 809-D)
At 1:08pm, while standing in garage area, LPA Quiroz observed a ziploc bag of cannabis. This was verified with (L/AD) Sofroni who indicated "Garage is always locked and secured. I've had plumbers working on the garage lately and don't know who that belongs to." (See LIC 9102 TV)
At 12:33pm, while conducting tour of outdoor premises, LPA Quiroz observed 4 vehicles parked on facility driveway, of which 3 of 4 have expired tags and not operable. (L/AD) Sofroni indicated "Yeah they have expired tags, bad batteries and not permitted to be operated on the public road until tags are renewed." (See LIC 809-D)

The facility is being cited per Title 22, Division 6 of the California Code of Regulations.

An exit interview was conducted with (L/AD) Sofroni, and a copy of this report, 809-D pages, LIC 9102-TV and Appeal Rights were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
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 2


Document Has Been Signed on 03/12/2024 02:38 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: NS CARE
FACILITY NUMBER: 306004454

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/19/2024
Section Cited
CCR
87203

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87203: Fire Safety-All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not being met as evidenced by: At 1:02pm while CONT...
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(L/AD) Sofroni agreed to have garage cleaned by POC due date of 3/19/2024 and submit proof of correction via pictures email to CCL by POC due date.
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CONT...conducting tour in the garage area, LPA Quiroz observed clutter and not able to walk through the garage area. This was verified with (L/AD) Sofroni who indicated "Yeah, it's bad. I know need to clean it." This poses a potential risk to residents in care
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Type B
03/21/2024
Section Cited
CCR87307(d)(6)

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87307(d)(6) Personal Accommodations and Services: (d)The following space and safety provisions shall apply to all facilities:(6)All outdoor and indoor passageways and stairways shall be kept free of obstruction. At 12:33pm, while conducting tour of outdoor premises, LPA Quiroz observed CONT...
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4 vehicles parked on facility driveway, of which 3 of 4 have expired tags. "Yeah they have expired tags and not permitted to be operated on the public road until tags are renewed." (L/AD) Sofroni agreed to have all current registrations for all vehicles on facility driveway and to operable by POC due date of 3/21/2024.

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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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 03/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2