<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005812
Report Date: 06/01/2021
Date Signed: 06/28/2021 11:53:39 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: 3DATE:
06/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Agoston "Gus" AgostonTIME COMPLETED:
03:30 PM
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 Analyst (LPA) Michelle Reed made an unannounced visit to facility to conduct an Annual visit. Upon arrival LPA met with Gus and Melinda Agoston and discussed the purpose of visit.

During the visit LPA toured the facility inside and out with. LPA observed Covid signage at front entrance of facility as well as a sanitization station. Facility has required Department postings. LPA observed a copy of Administrators Certificate expiring 7/2/21 for Gus Agoston. LPA toured all resident rooms, all rooms appeared clean and sanitary. All restrooms observed contained ample supplies of hand sanitizer, soap, wipes, gloves and paper towels. LPA observed outside visitation areas with ample shading. Residents were observed Licensee has required Mitigation plan and Emergency Disaster Plan. LPA also observed emergency food and water supply. Facility has a secured location for resident medication and files.

During the visit, LPA consulted with Administrator regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA discussed sign in and screening procedures for visitors. -LPA advised the importance of mask wearing and handwashing for staff at all times. PIN 21-17.2-ASC was also discussed.

No deficiencies noted during visit. An exit interview was conducted with Administrator Gus Agoston and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 1