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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005712
Report Date: 10/17/2022
Date Signed: 10/17/2022 11:14:08 AM

Document Has Been Signed on 10/17/2022 11:14 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: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:
10/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ana MoraTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with Administrator Ana Mora and stated the purpose of this visit.

The facility is a single level structure and licensed for six-ambulatory clients. This facility is an Adult Residential Facility for the Elderly.

At about 9:30 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed no clients at the facility as they were out in the community. LPA toured the interior and exterior portions of the facility. There were 3 client rooms 2 of which were shared rooms. Facility also had a staff room and a vacant/office room. Client rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Restrooms were observed to be in good repair and hot water was measured at 106.7 degrees Fahrenheit. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements. Facility had adequate supplies of personal protective equipment in place. Fire extinguisher was observed. Fire alarms and carbon monoxide alarm were tested to be operational. Facility offers a 2 -car garage which is mainly used for storage with a refrigerator, an operational washer/dryer and emergency food supplies. Kitchen was in good repair with cleaning supplies and sharp items inaccessible to clients in care.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2022
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: VARGAS HOME
FACILITY NUMBER: 306005712
VISIT DATE: 10/17/2022
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For the exterior portion, facility had patio furniture in good repair; and grounds were free of tripping hazards. Backyard also had a shed for storage and an office. LPA Tapia reviewed the COVID 19 mitigation plan and the Emergency Disaster of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed.

LPA Tapia conducted an exit interview with Administrator Ana Mora and a copy of this report was explained and left at the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Edward Tapia
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2022
LIC809 (FAS) - (06/04)
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