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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005712
Report Date: 10/22/2021
Date Signed: 10/22/2021 01:15:06 PM

Document Has Been Signed on 10/22/2021 01:15 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:VARGAS HOMEFACILITY NUMBER:
306005712
ADMINISTRATOR:MORA, ANAFACILITY TYPE:
735
ADDRESS:2814 WAVERLY AVETELEPHONE:
(714) 602-7593
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 5DATE:
10/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Ana Luisa Mora TIME COMPLETED:
01:15 PM
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Licensing Program Analysts (LPAs) Michelle Reed and Jerome Haley conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPAs were greeted and granted entry into the facility by Administrator Ana Lusia Mora and Caregiver Hugo Mora. LPAs explained the reason for the visit. Administrator Ana has a current administrator certificate expiring on 06/21/2022.

At 12:00 noon, LPAs toured the facility with Caregiver Mora and Administrator Ana. Facility has two clients present during today's visit, with three clients at day program. LPAs observed clients relaxing in the facility. LPAs spoke with two clients who appeared happy and well taken care of. All client rooms had the required elements including air filtration systems equipped with UV lighting. The restrooms were stocked with soap/ sanitizer, and paper towels. LPAs observed the screening/ sanitizing station in the entrance of the facility. Both LPAs were pre-screened and temperatures were taken upon entering the facility. Facility takes client and staff temperatures daily and documents. Facility has covid precaution postings as well as all required department postings. The facility mitigation plan has been completed and approved. LPAs observed adequate emergency food as well as the first aid kit. First aid kit contained all required items. LPAs observed locked medication drawer. Fire extinguishers were observed and charged. LPAs toured the outside grounds and observed multiple shaded visitation areas equipped with tables and chairs. Exit gates are unlocked and self latching. LPAs observed the posted activity schedule including exercise, sports, and gardening. Facility has a plan for covid testing clients and staff as needed as well as a plan for isolation. All staff and all clients are fully vaccinated for Covid-19 and have all received their booster shoot. LPA Reed reviewed and signed covid mitigation plan for the facility.

LPA Reed consulted with Administrator on the importance of maintaining proper building permits for any construction on the facility. As well as the importance of staff always wearing a mask while inside the facility.

No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was provided to AD Ana Luisa Mora.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Michelle Reed
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2021
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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