306005388-5-4-2026-22-AS-KSGH-DUGL7Z-20260527083109

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005388
Report Date: 05/04/2026
Date Signed: 05/04/2026 04:08:57 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2026 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20260429103945

FACILITY NAME:	VA & C HOMES/SAN RAFAEL		FACILITY NUMBER:	306005388
ADMINISTRATOR:	ANTHONY AU		FACILITY TYPE:	735
ADDRESS:	6222 SAN RAFAEL DRIVE		TELEPHONE:	(714) 952-9641
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY:	6	CENSUS: 1	DATE:	05/04/2026
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Maxine Kniazeff		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not report a change in client's condition.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to the begin the investigation in to the complaint allegation listed above. LPA explained the purpose of the visit upon entry. The complaint investigation consisted of interviews and document review.

Regarding the allegation: Staff did not report a change in client's condition.

0 of 5 individuals interviewed could provide any supporting evidence or information that supports the complaint allegation. Four individuals denied the allegation and document review revealed information that contradicts the compliant allegation.

During interviews, it was discovered C1’s condition began to change at the end of last year (2025). Due to the clients age and decline, facility staff requested some of C1’s medications be decreased.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260429103945

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/04/2026

NARRATIVE

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Once C1’s medication were decreased, the first change was observed in late October. C1’s appetite began to decrease and when facility staff observed the decrease in appetite, C1 was taken to the hospital October 28, 2025, due to a decrease in appetite and agitation. C1 was not admitted to the hospital at that time and the decrease in appetite was thought to be a symptom of withdraw because C1’s medication were recently decreased.

Over the next few months, C1 was seen by physicians and sent to the ER for different reasons including a scheduled January 29, 2026, surgery at UCI, and a post-surgery follow up visit that was rescheduled for February 5, 2026. C1 also had labs done three different times: January 26, 2026, February 13, 2026, and April 14, 2026.

According to witness 1 (W1), facility staff made sure C1 made all their appointments and C1 was healthy prior to their recent hospitalization April 20, 2026. According to W1, C1’s health declined rapidly, but facility staff were not responsible for any neglect.

Document review confirmed the statement made by W1, as C1 was not in any acute distress, and appeared to be well developed according to West Anaheim Medical Records dated October 28, 2025. A post-surgery hospital visit discharge summary from UCI dated February 5, 2026, reveal C1 was recovering as expected and no concerns were noted. In fact, C1 received an okay to return to their day program on February 13, 2026.

Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed unsubstantiated.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026

LIC9099 (FAS) - (06/04)

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