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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005388
Report Date: 11/16/2023
Date Signed: 11/16/2023 01:34:35 PM

Document Has Been Signed on 11/16/2023 01:34 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:
11/16/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Maxine Kniazeff - Administrator TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced Case Management visit to the facility to serve an Immediate Exclusion Order. LPA Mendivil met with Administrator Maxine Kniazeff, and explained reason for visit.

The Immediate Exclusion Order for Staff Yulzian Balce was explained to Administrator Maxine Kniazeff which is for the following facilities: VA&C Homes/ San Rafael (3060005388), VA&C Homes/ Bridgeport (306005385), VA&C Homes/San Paco Circle (306005930) VA&C Homes/Teranimar (306005931).

Administrator Maxine Kniazeff stated will disassociate Staff Yulzian Balce from VA&C facilities and provide proof to LPA by 11/17/2023.

All parties understood the Immediate Exclusion Order, and there were no additional questions.

A copy of this report was provided and explained.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2023
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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