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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005558
Report Date: 03/14/2025
Date Signed: 03/14/2025 03:42:15 PM

Document Has Been Signed on 03/14/2025 03:42 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: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:
03/14/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:26 PM
MET WITH:Olivia Hidayat-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On this day Licensing Program Analysts (LPA) Alvaro Ramirez, Jr. made an unannounced Plan of Correction (POC) visit in conjunction with the Case Management and citations issued on March 04, 2025. LPA was greeted and granted entry into the facility by Administrator (AD) Olivia Hidayat. LPA explained the reason for the visit.

During today's visit, LPA also conducted a Health and Safety inspection. AD Hidayat has a current Administrator Certificate with the expiration date of September 6, 2026. LPA and AD conducted a toured of the facility and observed the facility has electricity, water, and gas. Water temperature tested between 105.2 and 108.8 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 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. Fire extinguisher was observed to be fully charged with a service tag dated March 12, 2025. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable.

On 03/05/25, Licensee failed to correct the following:


*Deficiency cited under Title 22 Regulation 80066(f) pertaining to Personnel Records (In all cases, personnel records shall document the hours actually worked). As of 03/14/25, Deficiency cited under Personnel Records has been not been CLEARED; a Deficiency and Civil Penalty was issued today.


CONTINUED ON LIC9099-C...
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VH HOME II
FACILITY NUMBER: 306005558
VISIT DATE: 03/14/2025
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During today's visit LPA review the VH Home II time sheets dated October 2024 to February 2025 for Staff 1 (S1). Per time sheet dated November 7, 14, 21 and 28, 2024, S1 worked from 4:00pm-6:00pm and 12:00 am-5:00am or from 12:00am-5:00am. LPA reviewed documents including the Personnel Report (LIC500) dated November 13, 2024. Per Personnel Report on Thursdays S1 is schedule to work from 5:00pm-7:00pm. LPA also reviewed the time sheet dated November 2024 to March 2025 fro S2. Per time sheet dated November 2024 to January 2025, on Wednesdays S1 worked from 7:00pm-12:00am. Per Personnel Report on Wednesdays S2 is schedule to work from 5:00pm-7:00pm. Therefore, the time sheets for S1 and S2 do not match the hours scheduled on the Personnel Report.

Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with Administrator Hidayat and a copy of this report was provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/14/2025 03:42 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 03/14/2025 at 02:54 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: 03/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2025
Section Cited
CCR
80066(f)

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Personnel Records 80066 (f) In all cases, personnel records shall document the hours actually worked.
This requirement was not met as evidence by:
Based on records reviewed the time sheets for S1 and S2 do not match the hours scheduled on the Personnel Report.
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Per Licensee they will provide an updated Personnel Report (LIC500). Licensee agreed to complete and email the completed time sheets for S1-S7 to LPA by POC date.
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Per time sheet for S2 it was left blank the month of February 2025. This poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
03/15/2025
Section Cited
CCR80012(a)

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False Claims 80012(a) (a) No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement was not met as evidence by:
Based on records reviewed the hours on the
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Licensee agreed to read the regulation and sign a statement of understanding. Licensee to email POC to LPA by POC due date.
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time sheets for S1 and S2 do not match the hours schedule to work on the Personnel Report.
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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:Sheila Santos
LICENSING EVALUATOR NAME:Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2025


LIC809 (FAS) - (06/04)
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