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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005520
Report Date: 10/25/2024
Date Signed: 10/25/2024 03:17:30 PM

Document Has Been Signed on 10/25/2024 03:17 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:BUENA VISTA HOMEFACILITY NUMBER:
306005520
ADMINISTRATOR/
DIRECTOR:		TUASON, LIEZLFACILITY TYPE:
734
ADDRESS:17777 BUENA VISTATELEPHONE:
(714) 983-7277
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 5CENSUS: 5DATE:
10/25/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Raymund Libang & Gregory AndresTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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An informal conference was conducted on this date in the Orange County Adult and Senior Care Regional Office (RO). The purpose of this informal conference was to discuss concerns regarding the operation of the facility.

Present during this meeting were Regional Manager (RM) Marina Stanic, Licensing Program Manager, Lydia Martinez, Licensing Program Analyst (LPA), Theresa Ta, Manager of Safety Net & Resource Development RCOC, Raymund Libang, Licensee. Gregory Andres, Licensee joined meeting through Virtual Teams.

During the informal conference, the following items were discussed:
* Arbitration Award dated September 20, 2024
* Dissolution of Corporation

The following was agreed to:
* RO and RCOC will finalize transition plan by November 1, 2024.
* Additional visits will be conducted by RO and RCOC during transition period to ensure continuation of quality of care and services to the Clients in compliance with regulation.

Licensee was aware of the Award and failed to notify RO timely. An exit interview was conducted and a copy of this report LIC809, LIC809D and Appeal Rights was provided to Licensees Libang and Andres.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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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Document Has Been Signed on 10/25/2024 03:17 PM - It Cannot Be Edited


Created By: Lydia Martinez On 10/25/2024 at 02:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: BUENA VISTA HOME
FACILITY NUMBER: 306005520

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2024
Section Cited
CCR
80061(a)(e)(1)

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Reporting Requirements (a) Each licensee or applicant shall furnish to the licensing agency reports as required by the Department, including, but not limited to, those specified in this section. (e) The items below shall be reported to the licensing agency within 10 working days
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Licensee provided copy of the Award on 10/25/2024
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following the occurrence. (1) The organizational changes specified in Section 80034(a)(2). This requirement is not met as evidenced by: Award of dissolution dated 9/20/2024 was not reported timely
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lourdes Montoya
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2024


LIC809 (FAS) - (06/04)
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