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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005558
Report Date: 03/04/2025
Date Signed: 03/04/2025 12:25:36 PM

Document Has Been Signed on 03/04/2025 12:25 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:
03/04/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:41 AM
MET WITH:Olivia HidayatTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit as the Licensee has did not appear for an in-person office meeting. LPA met with Administrator (AD) Olivia Hidayat and explained the purpose of the inspection

Noncompliance Conferences (NCC) were scheduled for September 17, 2024, January 10, 2025, January 30, 2025, February 26, 2025. Licensee did not appear to all four scheduled meetings and did not communicate with Community Care Licensing (CCL). Licensee also did not appear for NCC scheduled for February 28, 2025 as Plan of Correction for deficiency cited on February 27, 2025 during case management inspection; civil penalty will be assessed for failure to correct.

During today's inspection, AD was also unable to provide LPA with time sheets for five of seven staff.

Based on observations made during today’s inspection, one deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. Civil penalty will also be assessed, see LIC421FC. 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: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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 03/04/2025 12:25 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 03/04/2025 at 12:02 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: 03/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/05/2025
Section Cited
CCR
80066(f)

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In all cases, personnel records shall document the hours actually worked.

This requirement is not met as evidenced by:

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AD stated they will provide LPA with a copy of documention of personnel records of actual hours worked via email by POC date.
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Based on AD interview and records review, the licensee did comply with the section cited above as documentation of personnel records of actual hours worked could not be provided for five of seven staff, which poses a immediate health, safety, and personal rights 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: 03/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2025


LIC809 (FAS) - (06/04)
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