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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 02:06:24 PM

Document Has Been Signed on 03/04/2025 02:06 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:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Olivia HidayatTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry Staff Lorna Sapaden. Administrator (AD) Olivia Hidayat was present at the facility and the purpose of the inspection was discussed.

During the inspection, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, garage and observed the following:

This is a one-story home with four client bedrooms, two staff rooms, three bathrooms, and attached two-car garage. All client bedrooms had the required furnishings. LPA observed all client beds had linens and blankets. LPA observed all windows were screened. The backyard has a shaded sitting area. LPA observed one of four clients present. Client was observed engaging in day program via zoom. Per AD, three clients were away at day program. Bathrooms were observed to be free of debris and mildew, and faucets and toilets were operational. Water temperature tested at 118.4 degrees Fahrenheit. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be fully charged with a service tag dated March 12, 2024. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Sharps and all toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to clients. Medication cabinet was observed to be locked. LPA reviewed medication and medication administration records for four of four clients and did not observe any discrepancies.

(Cont. LIC809-C)

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 306005558
VISIT DATE: 03/04/2025
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LPA reviewed four of four client files and seven of seven staff files. Files were observed to contain all required documentation. Staff files were observed to contain required 16-hour initial staff training, which includes: Principles of nutrition, food preparation and storage and menu planning, Housekeeping and sanitation principles, Provision of client care and supervision, including communication, Assistance with prescribed medications which are self-administered, Recognition of early signs of illness and the need for professional assistance, and the Availability of community services and resources. Staff files also include 22 hours of annual staff training thereafter.

Activity calendar was observed to be posted and includes board games on Monday, Arts and Crafts on Tuesday, Music/Dance on Wednesday, Yoga on Thursday, and table games on Friday. LPA observed facility to have board games, arts and crafts supplies, and table games stored in the dining room. Activity calendar indicated Saturday activities are park/picnic/community walk/family time, and Sunday activities are church/backyard bbq/outing/family time. Per AD, the weekend is a choice of any of the activities posted on the calendar and stated there is typically one client present at the facility on the weekend, as three of four clients opt for family time and will go home for the weekend. AD stated there are two staff scheduled on the weekends as indicated on personnel report. LPA interviewed Client 1 (C1) who was present. C1 stated they are assisted with activities of daily living, attend day program, engage in activities at the facility they enjoy, and stated they will usually go home on the weekends to be with family. C1 denied any concerns regarding the facility or staff.

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: 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
LIC809 (FAS) - (06/04)
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