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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005812
Report Date: 06/10/2020
Date Signed: 06/10/2020 10:30:37 AM

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 CAREFACILITY NUMBER:
306005812
ADMINISTRATOR:VASS, AGOSTONFACILITY TYPE:
740
ADDRESS:10402 LADERA SENDATELEPHONE:
(714) 624-5277
CITY:SANTA ANASTATE: CAZIP CODE:
92705
CAPACITY:6CENSUS: 0DATE:
06/10/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Gus VassTIME COMPLETED:
10:40 AM
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Licensing Program Manager (LPM) Alisa Ortiz and Licensing Program Analyst (LPA) Kimberly Lyman contacted the facility via telephone to conduct a subsequent pre-licensing visit via What's App due to COVID-19 and pre-cautionary measures. LPM and LPA 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. Licensee's daughter Vivian Vass was present during the visit.

LPM and LPA toured the facility via What's App and observed the following:
  • Licensee has repaired the door frame in room #3 as well as installed auditory exit alarms.
  • Licensee has posted required Community Care Licensing (CCL) postings at the entry of the facility.
  • Licensee has installed a fence around the perimeter of the facility as well as an outdoor shaded seating area.
  • Licensee updated the emergency disaster plan to include evacuation areas outside facility property.
At 10:00 AM, LPM and LPA resumed the virtual visit at licensee's current facility (306001770) to observe requested items to be transferred from current facility to new facility once licensed. LPM and LPA observed the following:
  • Licensee has ample supply of linens.
  • Licensee has emergency food and water supply.
  • Licensee has a locked cabinet to store medications and files to be moved once facility is licensed.
  • Licensee has a complete first aid kit as well as a first aid manual.
Licensee has completed the noted corrections and is ready to be licensed.

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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2020
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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