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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005383
Report Date: 01/06/2025
Date Signed: 01/06/2025 11:19:00 AM

Document Has Been Signed on 01/06/2025 11:19 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VA & C HOMES/BRIDGEPORTFACILITY NUMBER:
306005383
ADMINISTRATOR/
DIRECTOR:		ANTHONY AUFACILITY TYPE:
735
ADDRESS:2859 W. BRIDGEPORT AVE.TELEPHONE:
(714) 952-9641
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 6DATE:
01/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Maxine KniazeffTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
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On this day Licensing Program Analysts (LPAs) Rose Ruppert and Fred Arias made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 clients. The home currently has 6 clients. Administrator (AD) Maxine Kniazeff arrived shortly to conduct facility tour. AD Kniazeff has a valid certificate that expires on 7/28/2026. AD provided updated liability insurance that expires on 1/31/2025.

LPAs along with staff member June toured the facility at 8:40 AM. LPAs toured the physical plant, checked food service, facility documentation and the first aid kit. The home consists of 6 client bedrooms, living room, dining room, and kitchen as well as 3 restrooms. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were functioning and shower was free of mold/mildew. Water temperature measured between 105.9 degrees F and 106.7 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. LPAs toured the kitchen and observed sharps locked in a cabinet during today's visit. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit. Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. LPAs reviewed the infection control and emergency disaster plans and plans are complete and thorough. Facility conducts monthly emergency drills with the last drill conducted on 12/5/2024. Outside grounds were toured. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. Gate latches on both sides of the facility were found not functional. The glass panel window by restroom 1 was found to be cracked. First aid kit contained all required items including tweezers, scissors and thermometer. There is shaded outdoor seating for clients. Exit gates are unlocked. LPAs observed the emergency food and water supply. LPAs reviewed 6 client files and 3 staff files.
CONTINUED ON LIC 809C DATED 1/6/2025
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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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Document Has Been Signed on 01/31/2025 11:34 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/31/2025 11:28 AM


Created By: RoseMarie Ruppert On 01/06/2025 at 10:40 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: VA & C HOMES/BRIDGEPORT
FACILITY NUMBER: 306005383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and interview, gate laches were found to be broken and misaligned. The window in restroom1 was found to be cracked. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/20/2025
Plan of Correction
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Administrator (AD) will provide LPA documentation and photos for the fixed gate latch and replaced restroom window. AD to email LPA by POC due date.

*****This is an amended report*****
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Ortiz
LICENSING EVALUATOR NAME:RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VA & C HOMES/BRIDGEPORT
FACILITY NUMBER: 306005383
VISIT DATE: 01/06/2025
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All client files contained required documentation including admission agreements, physician reports, client appraisals. Staff files reviewed contained required documentation including required annual training, medical assessment/ TB, criminal record clearance and proof of CPR training. LPAs reviewed medication storage and administration. Medications are stored in a locked cabinet. Medications are being administered per physician order.

Based on the observations made during today’s visit, 2 deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. One technical violation has been issued. This report was discussed with the facility representative and a copy was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Fred Arias
LICENSING EVALUATOR SIGNATURE:

DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2025
LIC809 (FAS) - (06/04)
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