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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005388
Report Date: 01/24/2025
Date Signed: 01/24/2025 05:16:10 PM

Document Has Been Signed on 01/24/2025 05:16 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VA & C HOMES/SAN RAFAELFACILITY NUMBER:
306005388
ADMINISTRATOR/
DIRECTOR:		ANTHONY AUFACILITY TYPE:
735
ADDRESS:6222 SAN RAFAEL DRIVETELEPHONE:
(714) 952-9641
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY: 6CENSUS: 4DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Maxine Kniazeff & Augustine Au - AdminstratorsTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On January 24, 2025 at 8:00am, Licensing Program Analyst (LPA) Eboni Bentley conducted an unannounced, required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPA Bentley was greeted by Lead Care Staff (LCS) Amorsolo Barrientos, and stated the purpose of this visit. LCS Barrientos called Administrators (AD) Maxine Kniazeff and Augustine Au, who later arrived at the facility.

The facility is licensed for six (6) ambulatory clients, age 18 through 59 and offers Adult Residential Care.
This is a single-story house with six (6) client bedrooms and two (2) bathrooms. During the inspection, LPA Bentley observed four (4) staff and four (4) clients in care.

LPAs Bentley conducted a tour of the physical plant accompanied by AD Kniazeff and the following was observed: There were no bodies of water on the premises, all rooms were inspected, beds and bedding supplies were available, lighting was provided in all rooms, and storage for clients' personal belongings were observed in clients’ closets. Additional bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperatures measured at 113.3 degrees F and 114.9 degrees F.

All client bedrooms were clean, well-organized, and had all the necessary items and storage space. The kitchen was clean and organized. All knives and sharp objects were locked in a drawer near the sink. Hazardous cleaning chemicals were found in a locked cabinet, under the sink. A two-day supply of perishable food items and seven-day supply of nonperishable food items was observed in the pantry near the stove. There is a washer and dryer in the kitchen, observed to be in working condition. There is a locked cabinet near the dining room area with clients' medications. LPA observed hallways and walkways were free of obstruction. The facility has emergency food and water supply stored in closet, near the front entryway.

Continues on LIC 809-C page
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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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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/SAN RAFAEL
FACILITY NUMBER: 306005388
VISIT DATE: 01/24/2025
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The backyard was clean and free of clutter and debris. LPA Bentley observed a shaded patio area with variable seating options, and a table with chairs on the grass. The detached, two-car garage was clean and organized

During the visit, LPA Bentley observed the facility's infection control practices, plan of operation, and fire and disaster plan. The smoke detectors and carbon monoxide detectors were operable. The facility has one (1) fire extinguisher that was observed charged, mounted in the kitchen, and serviced on July 18, 2024. Fire and disaster training was last conducted on January 5, 2025.

A working telephone (714-952-9641) remains available, and the facility has a device that can be used for internet and video teleconference purposes. Liability Insurance is effective January 30, 2024 and expires on January 30, 2025 and AD has already requested a renewal. A first aid kit is properly maintained and contains all the necessary elements. A review of the Medication and Medication Administration Record (MAR) was conducted, and LPA Bentley observed the records are in compliance.

LPA Bentley conducted an audit of four (4) client files (R1-R4), five (5) staff files (S1-S5), and conducted interviews with three (3) staff and four (4) clients. The review of four (4) clients service files and five (5) staff personnel files revealed to be complete. The facility has the current administrators’ certifications on file for Maxine Kniazeff expiring July 28, 2026 and Augustine Au expiring July 29, 2026.

Based on observations made during today’s inspection, no deficiencies were cited during the time of the visit per Title 22, Division 6, of the California Code of Regulations.

An exit interview conducted and a copy of the report was provided to Administrator Maxine Kniazeff at the end of today’s visit.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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