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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005712
Report Date: 11/14/2024
Date Signed: 11/14/2024 12:46:41 PM

Document Has Been Signed on 11/14/2024 12:46 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VARGAS HOMEFACILITY NUMBER:
306005712
ADMINISTRATOR/
DIRECTOR:		MORA, ANAFACILITY TYPE:
735
ADDRESS:2814 WAVERLY AVETELEPHONE:
(714) 602-7593
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY: 6CENSUS: 5DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Ana MoraTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Lydia Martinez attempted to conduct an unannounced Required 1 - Year visit on 11/5/2024. LPA rang doorbell several times, no one answered. LPA attempted to contact the facility through telephone number (714) 602-7593 and got no answer. LPA attempted to contact Administrator at number (714) 278-5970 and got not answer. LPA will return to complete visit at a later date.

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On today's date, LPA Martinez made an unannounced visit to the facility to conduct a Required - 1 year inspection. LPA was allowed entry into the home and met with Licensee/Administrator Ana Mora and reason for visit was explained. AD Mora's Certificate expires on 06/21/2026.

No clients were present during today's visit. LPA, along with AD Mora toured the physical plant. LPA observed the facility to be clean, organized and in good repair. The home is maintained at a comfortable temperature. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each client comfortably. Client bathrooms were checked and toilets and water faucets work properly and shower was free of mold/mildew. Hot water temperature was within regulatory requirements. Client bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, and doorways were free of obstructions. Kitchen is clean and organized. Perishable and non-perishable food supply was checked and adequately stocked. Appliances are operating properly. LPA observed sharps and cleaning supplies are inaccessible to the clients. Smoke detectors and carbon monoxide detector tested operational; Fire extinguisher was fully charged and mounted. No bodies of water were observed outside. Walkways around the home were clear of hazards. Exit gates are unlocked and self-latching. LPA observed First Aid kit contained required items. Fire/Emergency drills are conducted monthly and LPA verified last Emergency Drill was conducted on 10/22/2024. LPA observed emergency supplies including food and water in the garage. LPA reviewed five client files, which contained current required documentation such as health assessments and admission agreements. (cont..LIC809C)

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VARGAS HOME
FACILITY NUMBER: 306005712
VISIT DATE: 11/14/2024
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Two staff files were reviewed. Staff files contained required documentation including fingerprint clearance and required training. Medication was observed to be in a centrally stored location and medication reviewed appeared to have been dispensed accurately. P & I money matched facility ledger. Liability and Surety Insurance certificates are current.

Based on observations made during today’s visit, no deficiencies are being cited. This report was discussed with AD Mora and a copy was sent to email on file.

SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024
LIC809 (FAS) - (06/04)
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