<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005558
Report Date: 04/28/2022
Date Signed: 04/28/2022 02:49:40 PM

Document Has Been Signed on 04/28/2022 02:49 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:VH HOME IIFACILITY NUMBER:
306005558
ADMINISTRATOR:HIDAYAT, OLIVIAFACILITY TYPE:
735
ADDRESS:10531 KEELSON AVETELEPHONE:
(714) 249-0002
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 6CENSUS: 3DATE:
04/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Olivia HidayatTIME COMPLETED:
12:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Administrator Olivia Hidayat and explained the reason for the visit. Administrator Hidayat has an administrator certificate expiring on 09/06/2022.

At 11:10 AM, LPA toured the facility with Administrator Hidayat. Facility has 3 clients in care during today's visit. LPA observed clients relaxing in the facility. All clients appeared happy and well taken care of. Facility appears clean and sanitary. All client rooms had the required elements. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a hand written visitor sign in sheet. Facility takes client and staff temperatures daily and documents. LPA observed the first aid kit has all required items. Smoke detectors tested operational during today's visit and fire extinguishers were fully charged. LPA observed sufficient supply of emergency food and water as well as emergency supplies. Food supply was sufficient. Toxins are secured. LPA observed a shaded outside visitation area. LPA observed the locked medication area. Facility utilizes a medication administration record. Facility provides activities in the form of exercise and games. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation and quarantine. LPA reviewed all client files during the visit and all files have updated emergency information as well as required documents. All clients and staff are vaccinated for Covid-19.

LPA consulted with Administrator on the importance of covid-19 signage outside the facility as well as taking visitor temperatures.

No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1