306005487-10-12-2022-22-AS-CDPO-CK5T77-20221012142816

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005487
Report Date: 10/12/2022
Date Signed: 10/12/2022 02:28:24 PM

Document Has Been Signed on 10/12/2022 02:28 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:	LA VACA HOMES		FACILITY NUMBER:	306005487
ADMINISTRATOR:	DOFREDO, WILFRED JOHN		FACILITY TYPE:	735
ADDRESS:	23302 LA VACA ST		TELEPHONE:	(949) 305-8163
CITY:	LAKE FOREST	STATE: CA	ZIP CODE:	92630
CAPACITY: 4		CENSUS: 4	DATE:	10/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Staff on duty - Herminigildo Cendana		TIME COMPLETED:	02:50 PM

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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced required annual inspection focusing primarily on the Infection Control. LPA De Perio explained reason for visit and was greeted and granted entry by staff on duty who checked temperature prior to entering facility. During the visit, 1 staff was on duty, who contacted facility administrator (AD) John Dofredo about visit. AD Dofredo was unable to be present during time of visit, however, provided consent for staff on duty (S1) to conduct tour, receive and sign report. As of 10/12/22, there are 0 active COVID-19 cases in the facility as verified. LPA De Perio observed the COVID-19 precautionary signs posted at the entrance of the facility. The PUB475 "See Something, Say Something" poster was observed to be located in the kitchen LPA De Perio observed the Administrator's Certificate for Wilfred John Doferdo, which expires on 8/24/23.

LPA De Perio toured the interior and exterior portions of the facility with S1. The facility is a single level structure and is licensed for 4 clients, ages 18-59 of which 4 may be may be ambulatory. Currently, there are a total of 4 clients in care, of which 2 clients were present during today's visit and 2 were attending Day Program. There are a total of 4 private client bedrooms. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards.

Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are two restrooms in the facility (one shared and one in a bedroom), of which both restrooms were observed to be in good repair, and toilets were operational. Water temperature in restrooms were measured to be at 107.9 degrees Fahrenheit and hand washing signs were also posted.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to clients in care and located in the kitchen. Fire extinguisher was charged, mounted and located in the living room.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: LA VACA HOMES	FACILITY NUMBER: 306005487
	VISIT DATE: 10/12/2022

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LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the hallway facility. Facility had back-up emergency food and water supply, located in the garage.

For the exterior portion, LPA De Perio observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, of which only one is utilized as an exit and was self-closing and self-latching. No bodies of water were observed.

LPA De Perio observed that First Aid Kit had all the required components. The facility had an adequate supply of PPE that was located in a cabinet in the garage. Medications were locked in a drawer located by the kitchen. Toxins were also observed to be locked, inaccessible to clients and located in the garage.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with S1. LPA De Perio discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. No citations were issued.

LPA De Perio discussed with S1 to review, and subscribe for emails regarding the Provider Information Notices (PINs) as well as to attend the CCLD Informational Calls to ensure that facility and staff are up to date. The PINs can be accessed at: www.ccld.ca.gov.

LPA De Perio discussed the California Code of Regulations Section 85075.4 Observation of the Client and Sections 80061 and 85061 Reporting Requirements with S1.

LPA De Perio advised S1 to use the general email address:
CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with S1 and a copy of this report, and copies of the regulations discussed were provided to the facility.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Celine DePerio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2022

LIC809 (FAS) - (06/04)

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