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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005558
Report Date: 09/25/2024
Date Signed: 09/25/2024 07:03:16 PM

Document Has Been Signed on 09/25/2024 07:03 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:
09/25/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:20 PM
MET WITH:Maximilian "Edgar" Timothy
Julita Paulino		TIME VISIT/
INSPECTION COMPLETED:
07:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez and Regional Center Quality Assurance Coordinator (QAC) Carole Suzuki made an unannounced case management visit for the purpose of conducting a health and safety inspection. LPA and QAC were greeted and granted entry by Staff Julita Paulino. Assistant Administrator (AAD) Maximilian “Edgar” Timothy arrived at the facility at 4:33 p.m., and the reason for the visit was discussed.

LPA, QAC, and AAD conducted a toured of the facility and observed the facility has electricity, water, and gas. Water temperature tested at 113.3 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 disinfects were observed to be inaccessible to clients.

LPA reviewed a current copy of staff schedule, which did not include specific hours and times. An LIC500 was not available for review. Interviews were conducted with three of three staff present. During their interview, Staff 1 (S1) stated their work schedule is Monday thru Friday from 6 a.m. – 9 a.m. and Monday thru Friday 2 p.m. – 7 p.m. During their interview, Staff 2 (S2) stated their work schedule is Saturday thru Wednesday 6 a.m. – 9 a.m. and Saturday thru Wednesday 2 p.m. – 7 p.m. Staff 3 (S3) stated their work schedule is Monday thru Friday 7 p.m. – 11 p.m. and Saturday thru Sunday 7 a.m. – 7 p.m. S3 also stated they are the on-call overnight staff. Per S3, they receive a salary and therefore work a 48-hour shift over the weekend. Per Regional Center requirements, overnight staff must be awake.

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: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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 09/25/2024 07:03 PM - It Cannot Be Edited


Created By: Claudia Gutierrez On 09/25/2024 at 06:46 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: 09/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2024
Section Cited
CCR
85065.6

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(g) In facilities providing care to Regional Center clients who rely upon others to perform all activities of daily living, night supervision shall be maintained as required by the Regional Center...

This requirement is not met as evidence by:
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AAD stated they will develop a plan of action to ensure there is overnight staff to meet Regional Center night supervision requirements and provide LPA with a copy via email by POC date.
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Based on staff interview, the licensee did not comply with the section cited above as night supervision is not being maintained as required by the Regional Center, which poses an immediate 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: 09/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2024


LIC809 (FAS) - (06/04)
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