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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005487
Report Date: 11/25/2024
Date Signed: 11/25/2024 01:38:38 PM

Document Has Been Signed on 11/25/2024 01:38 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:LA VACA HOMESFACILITY NUMBER:
306005487
ADMINISTRATOR/
DIRECTOR:
DOFREDO, WILFRED JOHNFACILITY TYPE:
735
ADDRESS:23302 LA VACA STTELEPHONE:
(949) 305-8163
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 4CENSUS: 4DATE:
11/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:John Dofredo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch conducted an unannounced visit for the purpose of an annual inspection. LPA was greeted and granted entry by facility caregiving staff after introducing himself and stating the purpose of the visit. Administrator John Dofredo was notified by telephone and arrived later to assist with the visit.

The facility is an Adult Residential Facility licensed for four ambulatory clients. There are currently four clients in care, only one of which is present during the visit. Other clients are at school, day program or visiting relatives in the community. The facility is a one-story home with four bedrooms, two bathrooms in addition to common areas and a kitchen. Facility appears clean, safe, and sanitary. All clients’ rooms had required elements, including bed, chair, closet space, and ample lighting. Facility had extra linens and hygiene supplies for all four clients. Hot water measured at 114 degrees Fahrenheit in one bathroom, 113F in the shared bathroom and 116.5F in the kitchen. LPA observed the facility had a two-day supply of perishables and a seven-day supply of non-perishable food was available as required by regulations. LPA observed hallways and walkways were free of obstruction. There are no bodies of water on the premises

LPA observed the fire extinguisher mounted on the living room wall is charged. Staff and LPA tested smoke and carbon monoxide detectors which were found to be operational. Cleaning products and sharp instruments are stored in a locked cabinet in the kitchen. Medication for each client is kept locked and secured in a cabinet in the dining room. The backyard has one shaded seating area, and the exit gate is unlocked and unobstructed. LPA reviewed all four clients’ files and medications as well as P&I records which were verified to correspond to the amount noted on the ledgers for the clients whose funds are managed by the facility. LPA reviewed six staff files. All files of staff and clients contained all required documentation. All current staff members are cleared and associated.
CONTINUED ON FORM LIC809-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE: DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/25/2024
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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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: LA VACA HOMES
FACILITY NUMBER: 306005487
VISIT DATE: 11/25/2024
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CONTINUED FROM LIC809
The Emergency and Disaster Plan was reviewed along with documentation of fire and emergency drills conducted monthly. Infection Control and Emergency and Disaster plans require an update, copies of the adequate forms provided.

No deficiencies were noted during today's inspection visit. An exit interview was conducted and a copy of this report was provided to the facility staff.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 11/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024
LIC809 (FAS) - (06/04)
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