306005812-5-13-2025-22-AS-BLOZ-DGMP9B-20250513110653

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005812
Report Date: 05/13/2025
Date Signed: 05/13/2025 11:07:10 AM

Document Has Been Signed on 05/13/2025 11:07 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	VASS SENIOR CARE		FACILITY NUMBER:	306005812
ADMINISTRATOR/ DIRECTOR:	VASS, AGOSTON		FACILITY TYPE:	740
ADDRESS:	10402 LADERA SENDA		TELEPHONE:	(714) 624-5277
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92705
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 3	DATE:	05/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:00 AM
MET WITH:	Caregiver Melinda Vass		TIME VISIT/ INSPECTION COMPLETED:	11:20 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	On May 13, 2025, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility for the purpose of conducting the required annual inspection. LPA was greeted and granted entry into the facility by care giving staff after explaining the purpose for the visit. Administrator (AD) Agoston Vass was notified via telephone but could not assist with today's inspection. LPA observed that Agoston Vass has a valid Administrator certificate which expires on July 2, 2025. The facility is a Residential Care Facility for the Elderly (RCFE) licensed for six non-ambulatory residents and has a hospice waiver for five. The facility is a two story home with three resident bedrooms, one of which is shared, one resident bathroom, a living room, a dining room, a kitchen, and an attached two car garage. LPA, accompanied by a caregiver conducted a tour of the interior portion of the facility. On today's visit, LPA observed three residents in care and one staff present. LPA observed residents relaxing in their respective bedrooms and in common areas. LPA observed the See Something, Say Something poster (PUB 475) mounted on the wall by the entryway of the facility. All resident bedrooms and the resident bathroom is located on the first floor of the facility. LPA inspected the three resident bedrooms and they were observed to be free of hazards. LPA observed residents bedrooms to have the required furnishings of a bed, a chair, a chest of drawers, and a lamp. LPA observed resident beds had clean linens and blankets. LPA observed additional linens to be stored in a hallway cabinet. LPA inspected the one resident bathroom. Resident bathroom was clean. Resident bathrooms were equipped with grab bars and non-skid floors. Faucets and toilets were operational. Hot water temperature measured 117.3 degrees Fahrenheit. LPA observed the second story of the facility to be for staff use only and off limits to residents in care. CONTINUED ON 809-C

Sheila Santos	TELEPHONE: (714) 703-2857
Brandon Lopez	TELEPHONE: (714) 483-4521
	DATE: 05/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

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 4

California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

Page: 2 of 4

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: VASS SENIOR CARE	FACILITY NUMBER: 306005812
	VISIT DATE: 05/13/2025

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
26
27
28
29
30
31
32

LPA observed the kitchen has a two day perishable and a seven day nonperishable food supply on hand. LPA observed kitchen appliances to be clean and operational. The five burner gas stove lights unassisted. LPA observed kitchen knives and sharps to be stored in a locked kitchen cabinet. LPA observed chemicals and toxins to be stored in a locked kitchen cabinet under the sink. LPA observed a fire extinguisher to be mounted on the wall by the dining room. The fire extinguishers were observed to be charged and up to date on service. LPA tested the wired smoke detectors/carbon monoxide detectors which tested operational. LPA observed the facility conducted their last emergency disaster drill on February 1, 2025.

LPA observed the centrally stored medication to be kept in a locked cabinet in the resident hallway. LPA observed the facility has a First Aid Kit stored in the resident hallway and it had all the required components. LPA observed chemicals and toxins to be stored in a locked cabinet in the resident hallway. LPA observed the facility has a three day emergency food and water stored in the pantry. LPA observed the door leading to the attached two car garage to be kept locked and inaccessible to residents in care. LPA observed the garage to be used for storage.

LPA, accompanied by the AD, conducted a tour of the exterior portion of the facility. The exterior portion was observed to be free of hazards and obstructions. LPA observed the perimeter gate on the east side of the facility to be self latching and can be opened in an evacuation. There are no bodies of water on the premises.

LPA reviewed all three resident files. LPA observed that per Resident #2 (R2) medical assessment, they have an ambulatory status of bedridden. However, the facility is not approved to retain a bedridden resident. LPA reviewed residents' medication and medication records. LPA reviewed two staff files. All staff are background cleared and associated to the facility.

Based on the observations made during today's visit, a deficiency is being cited on the attached 809-D and civil penalties are being assessed. An exit interview was conducted with Caregiver Melinda Vass. A copy of the report and Appeal Rights were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Brandon Lopez	TELEPHONE: (714) 483-4521
LICENSING EVALUATOR SIGNATURE:	DATE: 05/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/13/2025 11:07 AM - It Cannot Be Edited

Created By: Brandon Lopez On 05/13/2025 at 10:29 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: VASS SENIOR CARE	FACILITY NUMBER: 306005812
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During resident file review, LPA observed that the Physician's Report for Resident #2 (R2) stated that they are bedridden. The facility does not have a Fire Clearance to accept a bedridden resident.
	POC Due Date: 05/14/2025
	Plan of Correction
1 2 3 4	Facility staff agreed to submit a new Fire Clearance request to CCL to retain a bedridden resident. Facility staff will submit the required documents for the new Fire Clearance request to LPA via email or fax by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Sheila Santos
NAME OF LICENSING PROGRAM MANAGER:

TELEPHONE: (714) 703-2857

	Brandon Lopez
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (714) 483-4521

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4