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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005812
Report Date: 06/17/2022
Date Signed: 06/17/2022 10:16:39 AM


Document Has Been Signed on 06/17/2022 10:16 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
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: 5DATE:
06/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Melinda Vass, Vivien VassTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with staff Melinda Vass and stated the purpose of this visit. Administrator Agoston Vass was not able to make the visit.

The facility is a two-level structure and licensed for six non-ambulatory of which five can be on hospice. This facility offers Residential Care for the Elderly.

At about 8:30 am, LPA Tapia was granted entry but was not asked to complete the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed five clients in care and one staff member on duty. LPA toured the interior and exterior portions of the facility. There were three resident rooms two of which are shared rooms, but all rooms have the potential to be shared rooms. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Manual smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. Bathroom (1) was observed to be in good repair and provided with grab bars and hot water was measured at 120.5 degrees Fahrenheit. LPA observed an operating washer/dryer and a freezer in an area between the resident’s rooms. LPA toured the second floor of the facility and was made aware that it was only for family/staff. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to residents in care. Facility did not have adequate supplies of personal protective equipment in place. Fire extinguisher was observed to be charged and operational. LPA did inform staff that date of charge tag needs to be kept on fire extinguisher, staff understood. For the exterior portion, facility backyard faces a hill with an incline and grounds were free of tripping hazards.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2022
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: 06/17/2022
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Facility also had a two-car garage which is used for storage and is kept locked. Kitchen was in good repair with knifes and cleaning supplies kept locked. LPA noticed some of medications were in the kitchen cabinets. Staff stated that they were for them and not residents. LPA informed staff that all medications need to be kept away from residents in care. LPA Tapia reviewed the COVID 19 mitigation plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed. No citation was issued. Eight advisories were issued today.

LPA Tapia conducted an exit interview with staff Melinda Vass and copy of this report was explained and left at the facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward TapiaTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC809 (FAS) - (06/04)
Page: 10 of 10