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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005300
Report Date: 08/25/2022
Date Signed: 08/25/2022 12:20:09 PM


Document Has Been Signed on 08/25/2022 12:20 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:VH HOME IFACILITY NUMBER:
306005300
ADMINISTRATOR:HIDAYAT, OLIVIAFACILITY TYPE:
735
ADDRESS:5122 W ROBERTS DRTELEPHONE:
(714) 775-5854
CITY:SANTA ANASTATE: CAZIP CODE:
92704
CAPACITY:4CENSUS: 4DATE:
08/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Olivia Hidayat, Joji TamioTIME COMPLETED:
12:30 PM
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On 08/25/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to VH Home I. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 9:41am, LPA Cho approached the facility, and LPA contacted the Administrator (Admin) Olivia Hidayat due to the front gate being locked. At 9:56am, Admin returned the call and informed the caregivers to unlock the gate. At 10:05am, LPA was greeted at the front gate by Caregiver Joji Tamio and was allowed entry into the facility at 10:07am. LPA completed the Coronavirus 2019 (COVID-19) screening procedure. Caregiver Jasmin Mendoza was also present at this time. Admin arrived at the facility at 10:48am. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. The Complaint Poster (PUB475) was observed in the required sizing. The The Administrator's Certificate for Olivia Hidayat expires on 09/06/2022.

The facility is a single level structure and licensed for four non-ambulatory clients. This facility offers a Level 3 service. As of today, there are four clients living in the facility. LPA observed three out of four clients in their respective bedrooms and one was at the day program.

At 10:22am, LPA Cho conducted a tour of the physical plant along with Caregiver Joji Tamio. The home consists of four client bedrooms with two client bathrooms. There is one staff bedroom, staff bathroom, and guest bathroom. The facility also has a living room, dining area, office, kitchen, and an attached two car garage/laundry area. The facility has mounted cameras outdoors and in the common areas of the facility. Two out of four client bedrooms were checked as Client 1 (C1) was sleeping and Client 2 (C2) had a minor cough due to a cold. The remaining two client bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew. Client bath towels and personal hygiene supplies were adequately stocked including paper towels and hand soaps.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2022
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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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: VH HOME I
FACILITY NUMBER: 306005300
VISIT DATE: 08/25/2022
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LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperature in the client bathrooms and the temperatures measured at 108.3 degrees Fahrenheit in Bathroom #1 and 107.7 degrees Fahrenheit in Bathroom #2.

LPA Cho inspected the kitchen along with Caregiver Tamio. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguishers were fully charged. The smoke and carbon monoxide detectors were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the clients. Auditory alarms were observed throughout the facility but were currently not in use. Per Admin, all four clients do not wander/run away and are able to ask permission prior to leaving the facility. After a discussion, LPA and Admin came to an agreement to utilize the auditory devices to ensure the safety of the clients.

LPA Cho toured the outside grounds with Caregiver Tamio. There were no bodies of water present. There was shading and sufficient seating for clients. Walkways around the home were clear of hazards, and the exit gates were self-closing and self-latching. There were no security bars or weapons on the premises.



LPA Cho reviewed the Emergency and Disaster Plan for Adult Residential Facilities (LIC610D). Facility had an outdated form, and Admin was advised to update the information utilizing the current LIC610D form per the Provider Information Notice (PIN 22-02-ASC) released on 01/06/2022. Facility does have back-up emergency food and water supply. The First Aid Kit met all the required components including the first aid manual, and the facility had sufficient PPEs.

No resident or staff files were reviewed at the time of this visit. LPA reviewed the COVID-19 mitigation plan of the facility. LPA provided the following guidance: to replace batteries for all auditory devices, and to update the LIC610D on the current form. As a reminder, LPA discussed the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102s) were issued during the visit. An exit interview was conducted with Administrator Olivia Hidayat, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
LIC809 (FAS) - (06/04)
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