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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005487
Report Date: 11/01/2021
Date Signed: 11/01/2021 10:29:35 AM

Document Has Been Signed on 11/01/2021 10:29 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:LA VACA HOMESFACILITY NUMBER:
306005487
ADMINISTRATOR:DOFREDO, WILFRED JOHNFACILITY TYPE:
735
ADDRESS:23302 LA VACA STTELEPHONE:
(949) 305-8163
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 4CENSUS: 4DATE:
11/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Wilfred Dofredo, AdminsitratorTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into the facility by caregiver and LPA explained the nature of the visit. Administrator arrived shortly after and met with LPA.

LPA Martinez began the tour of the facility, accompanied by Administrator. There are four clients in care and there are no active covid-19 cases in facility. LPA observed clients throughout the facility, all residents appeared to be clean and well taken care of. LPA observed required department postings, covid-19 precautionary postings in the facility. All restrooms observed to have ample supply of soap and appeared to be clean. All bedrooms observed to have all required components. LPA observed a check in station in the main entry of the facility. Facility is taking temperature daily and documenting the results. LPA observed the emergency disaster and evacuation plan. Facility has the back-up emergency food and water supply as well as PPE supplies in the attached garage. The facility has completed the LIC808 Mitigation Plan, LPA reviewed and approved the plan on today’s visit. LPA emailed the signed and approved plan to the Administrator for their records.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the Administrator and a copy of this report was provided to the facility.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2021
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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