306005812-5-20-2020-22-AS-KLYN-BPSQAK-20200520120004

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005812
Report Date: 05/20/2020
Date Signed: 05/20/2020 12:00:09 PM

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:	VASS SENIOR CARE		FACILITY NUMBER:	306005812
ADMINISTRATOR:	VASS, AGOSTON		FACILITY TYPE:	740
ADDRESS:	10402 LADERA SENDA		TELEPHONE:	(714) 624-5277
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY:	6	CENSUS:	DATE:	05/20/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Agoston Vass		TIME COMPLETED:	11:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPAs) Kimberly Lyman and Jenifer Tirre contacted the facility via telephone to conduct a pre-licensing visit via What's App due to COVID-19 and pre-cautionary measures. LPA's identified themselves and discussed the purpose of the call with Licensee/Administrator Agoston Vass. An initial application to operate a Residential Facility for the Elderly was received by CCL on 03/19/2020 for a capacity of 6 non-ambulatory residents. Pre-licensing is for a change of location. There are 0 residents in care during today's visit. LPAs Tirre and Lyman along with Administrator Vass toured the facility via What's App at 9:00 AM and observed the following: Structure: Facility is a two story, 7 bedroom, 3 bathroom house with an attached garage and a cream exterior. The second floor will not be housing any residents. Living Room/ Dining Room: Adequate seating is available in the dining room and living room. Bedrooms Residents: Two out of three resident rooms are missing basic accommodations including dresser, bed, night stand, and chairs. Furniture to be moved upon licensure. Exit doors in facility are not equipped with auditory exit alarms. The door frame in resident room #3 needs a door frame installed. Bathrooms: All resident bathrooms have a working toilet, wash basin, and bathtub/shower as well as grab bars and non-skid surface in the shower. Linens & Hygiene Supplies: Facility does not have any linens present at the facility. Emergency Phone Numbers and Exit Plan: Facility does not have any items posted at the facility. Food Service: Facility to obtain 2 day perishables as well as 7 day non-perishables in the pantry/ refrigerator, prior to admitting residents. Facility does not have an emergency food and water supply present at the facility. Smoke Detectors: Smoke detectors/ carbon monoxide detector are centrally wired and were tested operational. Fire extinguisher is mounted and charged. Appliances: Stove and refrigerator are operational. Facility microwave and washer dryer are not present at the facility. Toxins: LPAs observed toxins unsecured in the food pantry. Water Temperature: Tested and recorded at 118.0 degrees F. in facility bathrooms. Reading Material Games, and Equipment: Facility does not have any activity supplies present at the facility. CONT ON LIC 809C DATED 05/20/2020.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2020

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: VASS SENIOR CARE	FACILITY NUMBER: 306005812
	VISIT DATE: 05/20/2020

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Medications, First-Aid Kit & Book: Facility does not have a first aid kit or manual present at the facility. LPA's observed completed emergency disaster plan however, the plan is missing evacuation sites. Facility does not have a secured location for medications or facility files. Licensee states the secured cabinet will be moved once facility is licensed. Backyard: LPAs observed the facility perimeter is not secured by any fence with self latching gates or walls as required per regulation. LPAs did not observe any shaded, outdoor seating for residents. Fire Clearance: Approved for 6 non-ambulatory residents on 04/30/2020.

The facility is NOT ready to be licensed. Component III was waived due to Licensee presently operating another facility.

Licensee to correct the following items in order to be licensed:

All Community Care Licensing required postings to be posted in the entry of the facility including COVID-19 postings and visitors policy.
Door frame in resident room #3 to be installed as well as auditory exit alarms on all exit doors.
Facility to maintain an ample supply of linens in the facility.
Toxins stored in the food pantry to be secured in a location other than food storage area.
Facility to maintain an emergency food and water supply in the facility.
Facility emergency plan updated to include evacuation sites not located at the facility.
Licensee to remove items on the side of the house including ladders, pipes, wheelbarrow, pallets, buckets, and any other items posing a risk to residents in care.
Facility to maintain a first aid kit including a first aid manual present at the facility.
Facility to obtain a secured area for storage of medication and facility files.
Facility to install a fence around the perimeter of the facility with self closing latches, gate, or wall to protect the safety of residents.
Facility to obtain shaded, outdoor seating for residents.

Licensee to notify LPA upon completion of noted items. LPA will complete a visit to verify completion..

An exit interview was conducted with Licensee Vass via telephone and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2020

LIC809 (FAS) - (06/04)

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