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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005558
Report Date: 02/27/2025
Date Signed: 02/27/2025 04:33:46 PM

Document Has Been Signed on 02/27/2025 04:33 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:
02/27/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:11 PM
MET WITH:Julita PaulinoTIME VISIT/
INSPECTION COMPLETED:
04:48 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Claudia Gutierrez and Alvaro Ramirez, Jr. and Regional Center Quality Assurance Coordinator (QAC) Carole Suzuki and Jacqueline Puente made an unannounced case management visit as the Licensee has failed to appear for an in-person office meeting. LPAs were greeted and granted entry by Staff Julita Paulino. LPAs explain the reason for the visit. Administrator (AD) Olivia Hidayat was observed taking a client to a doctor's appointment.

The Noncompliance Conferences were scheduled for September 17, 2024, January 10, 2025, January 30, 2025, and February 26, 2025. Licensee failed to appear to all four scheduled meetings and did not communicate with Community Care Licensing (CCL).

During today's visit, LPAs observed AD certificate for AD Olivia Hidayat expired on September 06, 2024. Per Administrator Certificate Bureau the application certificate renewal was received on August 01, 2024, and is currently pending.

LPAs also conducted a Health and Safety inspection. LPAs and Staff Paulino conducted a tour of the facility and observed the facility has electricity, water, and gas. Fire extinguisher was observed to be fully charged with a service tag dated March 12, 2024. Water temperature tested between 117.3 and 117.5 degrees Fahrenheit. Client bedrooms were observed to have the required furnishings. Certificate of liability insurance has an expiration date of April 11, 2025. 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 cabinet and knives 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.

Based on observations made during today’s inspection, one deficiency is being 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 was provided at the end of the inspection..

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2025
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 02/27/2025 04:33 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 02/27/2025 at 03:54 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: 02/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2025
Section Cited
CCR
80063(a)

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The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation.

This requirement is not met as evidenced by:
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Licensee agrees to attend the Noncompliance Conference scheduled for Friday, February 28, 2025 at 2:00 pm in the Orange Regional Office.
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Licensee failed to appear for the Noncompliance Conferences scheduled for 09/17/24, 01/10/25, 01/30/25 and 02/26/25 and did not communicate with Community Care Licensing (CCL), which poses an immediately 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: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2025


LIC809 (FAS) - (06/04)
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