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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005558
Report Date: 11/08/2024
Date Signed: 11/08/2024 06:35:57 PM

Document Has Been Signed on 11/08/2024 06:35 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/
DIRECTOR:		HIDAYAT, OLIVIAFACILITY TYPE:
735
ADDRESS:10531 KEELSON AVETELEPHONE:
(714) 249-0002
CITY:GARDEN GROVESTATE: CAZIP CODE:
92843
CAPACITY: 6CENSUS: 4DATE:
11/08/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:55 PM
MET WITH:Julita PaulinoTIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Alvaro Ramirez made an unannounced case management visit for the purpose of conducting a health and safety inspection. LPAs were greeted and granted entry by Staff Julita Paulino and the purpose of the visit was discussed.

LPAs and Staff Paulino conducted a tour of the facility and observed the facility has electricity, water, and gas. Water temperature tested between 113.9 - 114.4 degrees Fahrenheit. Client bedrooms were observed to have the required furnishings. Certificate of liability insurance was observed to be posted and current. The kitchen was observed to be clean and organized and a 2-day supply of perishable and a 7-day supply of non-perishable food was observed. Medications are kept locked in a file cabinet and sharps are kept locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins, and disinfectants were observed to be inaccessible to clients.

LPAs reviewed a copy of Personnel Report (LIC500) for VH Home I and VH Home II and observed Administrator (AD) Olivia Hidayat is scheduled to work on Saturday and Sunday 7 a.m. – 7 p.m. at VH Home I and 8 p.m. – 6 a.m. at VH Home II. Per Regional Center requirements, overnight staff must be awake.

AD was unable to be present at the time of inspection due to a scheduled meeting with Department of Rehabilitation. LPAs provided Staff Paulino with a copy of Informal Office Meeting letter, which states attendance at the office meeting is mandatory, and AD is to contact LPAs in the event meeting requires rescheduling.

Based on observations made during today’s inspection, one deficiency is being re-cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report and appeal rights were provided at the end of the inspection.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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 11/08/2024 06:35 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 11/08/2024 at 03:51 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: VH HOME II
FACILITY NUMBER: 306005558

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2024
Section Cited
CCR
85065.6(g)

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(g) In facilities providing care to Regional Center clients who rely upon others to perform all activities of daily living, night supervision shall be maintained as required by the Regional Center...

This requirement is not met as evidenced by:
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Staff Paulino stated a plan of action will be developed to ensure there is overnight staff to meet Regional Center night supervision requirements and provide LPA with a copy via email by POC date.
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Based on staff interview, the licensee did not comply with the section cited above as night supervision is not being maintained as required by the Regional Center, which poses an immediate health and safety risk to persons in care.
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
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