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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005558
Report Date: 06/16/2023
Date Signed: 06/16/2023 11:39:50 AM

Document Has Been Signed on 06/16/2023 11:39 AM - 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:
06/16/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Maximilian Timothy
Olivia Hidayat		TIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced case management visit as facility was recently granted a new fire clearance. Fire Clearance was granted by a fire inspector of the Orange County Fire Authority (OCFA) on 06/07/2023 for (6) capacity, (2) ambulatory, (4) non-ambulatory, and (0) bedridden clients; special conditions noted “Approval for the office to be a bedroom for one ambulatory client. Non-ambulatory patients only permitted in bedroom #1, #2, and #5." LPA met with Assistant Administrator (AAD) Maximilian Timothy and conducted a tour of the premises. LPA observed the facility floor plan to be consistent with fire clearance and facility sketch approved by OCFA.

Administrator (AD) Olivia Hidayat arrived at 11:00 a.m. Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/16/2023
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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