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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005388
Report Date: 01/12/2024
Date Signed: 01/12/2024 11:01:39 AM

Document Has Been Signed on 01/12/2024 11:01 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 ASC, 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:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:TIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. made an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by House Manager, Amorsolo Barrientos. Assistant Administrator Augustine Au joined the inspection approximately 10 minutes after LPA's arrival.

The facility is a one-story home with six client bedrooms, two bathrooms, kitchen, dining room, living room, backyard and detached 2-car garage. LPA observed residents to be eating breakfast. Facility appears clean and sanitary. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Facility had extra linens for clients in the hallway closet. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 109.4 degrees Fahrenheit and 108.6 degrees Fahrenheit in the client bathrooms. LPA observed facility has emergency food and water supply. LPA observed hazardous items such as knives, chemicals and cleaners to be locked up in drawers in the kitchen. Cooking materials and chemicals are stored separately. Medication for each resident is kept locked in a cabinet in the dining room. The backyard has a shaded seating area. Exit gates are unlocked. LPA observed a couple of unused chairs, doors and recycling in the backyard. LPA advised staff to throw out any unused items. Pathways to exit gates appear to be unobstructed. LPA reviewed two of the four client files, two personnel files, all clients' medication and all client P&I. Files, Medication and P&I appear to be properly documented and stored. All clients at facility are non-verbal. In speaking with staff, LPA noted staff is thoroughly aware of client behaviors, triggers and propensities. Clients at facility engage in physical activities such as walks and exercise as well as activities in the facility like puzzles, games, arts and crafts, music and more.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was provided to the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/12/2024
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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