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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005388
Report Date: 01/26/2023
Date Signed: 01/26/2023 02:54:22 PM

Document Has Been Signed on 01/26/2023 02:54 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:VA & C HOMES/SAN RAFAELFACILITY NUMBER:
306005388
ADMINISTRATOR:ANTHONY AUFACILITY TYPE:
735
ADDRESS:6222 SAN RAFAEL DRIVETELEPHONE:
(714) 952-9641
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 4DATE:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Amorsolo Barrientos
Augustin Au		TIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted by staff Amorsolo Barrientos and granted entry into the facility. LPA Gutierrez discussed the purpose of the inspection. During the inspection LPA Gutierrez and staff Barrientos conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a single-story house with six bedrooms, and two bathrooms. During the inspection LPA observed three staff and four clients in care. Clients were observed resting in their respective bedroom and in the dining room area doing puzzles and listening to music. A 2-day supply of perishable and a 7-day supply of non-perishable foods was observed during today’s visit. Upon record review LPA noted emergency care requirements were met. LPA observed the facility does not have a 30-day supply of PPE on hand; a Technical Advisory was given on this date. LPA observed hallways and walkways were free of obstruction.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 testing, quarantine, isolation, cohorting, infection control training, PPE, and staffing.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. Administrator (AD) Augustin Au arrived at 2:44 p.m. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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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