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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005930
Report Date: 04/03/2024
Date Signed: 04/03/2024 01:59:21 PM


Document Has Been Signed on 04/03/2024 01:59 PM - 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:VA & C HOMES / SAN PACO CIRCLEFACILITY NUMBER:
306005930
ADMINISTRATOR:AU, ANTHONYFACILITY TYPE:
740
ADDRESS:6901 SAN PACO CIRCLETELEPHONE:
(714) 952-9641
CITY:BUENA PARKSTATE: CAZIP CODE:
90620
CAPACITY:6CENSUS: 0DATE:
04/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Maxine Kniazeff - Assistant AdministratorTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Jerome Haley and Edward Kim conducted an unannounced visit for the purpose of conducting a required one year annual inspection. LPAs Haley and Kim were greeted and granted entry by staff and explained the reason for the visit. Staff contacted Administrator Maxine (Maxima) Kniazeff who arrived a short time later and was present for the remainder of the of the visit.

During the inspection, all resident bedrooms and bathrooms were inspected. All resident bedrooms had the necessary elements and were in compliance with regulation guidelines. Both resident bathrooms were clean and organized. Hot water temperatures were measured in the range of 111.3 degrees Fahrenheit and 111.2 degrees Fahrenheit. No hazardous items were observed in the resident bathrooms, and all grab bars were tightly secured to the wall.

Resident medications, and P&I funds were locked in the cabinets in the facility office area. A first aid kit with all the required elements was locked in the cabinets as well. LPAs observed an emergency food supply, emergency water supply, and an emergency disaster kit in the closet near the front door.

In the kitchen, knives and sharp objects are kept locked in a drawer near the sink. Hazardous cleaning materials are kept locked under the sink. A perishable food supply that meets regulation requirements was observed in the refrigerator. A non-perishable food supply that meets regulation requirements was observed in the cabinets.

The garage was organized and free of clutter. There was a refrigerator in the garage with an additional supply of non-perishable food items, and several boxes of adult briefs were observed in the garage. There were also miscellaneous facility items being stored in the garage.

The backyard was clean, organized, and walkways were free of obstruction. The side exit gate is self-closing and self-latching.

Continued on LIC809C

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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 5


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: VA & C HOMES / SAN PACO CIRCLE
FACILITY NUMBER: 306005930
VISIT DATE: 04/03/2024
NARRATIVE
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Smoke detectors, and carbon monoxide detectors tested operational. A fully charged fire extinguisher was observed mounted on the wall in the kitchen.

An emergency evacuation drill was conducted April 1, 2024 and evacuation drills are conducted monthly for all staff on each shift.

Deficiencies are being cited as a result of today’s visit.

An exit interview conducted, and a copy of this report and appeal rights were provided to Administrator Maxine Kniazeff.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/03/2024 01:59 PM - It Cannot Be Edited

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: VA & C HOMES / SAN PACO CIRCLE

FACILITY NUMBER: 306005930

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPAs observed 2 pair of scissors in an unlocked file cabinet in the office area of the facility which posed a potential safety risk to persons in care.
POC Due Date: 04/05/2024
Plan of Correction
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Administrator Maxine Kniazeff locked up both pairs of scissors when they were observed unlocked. Administrator Kniazeff will make sure all knives and sharp objects remain locked at all times.
Type B
Section Cited
CCR
87217(g)(1)
(g) Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted in his care including, but not limited to the following:
(1) Records of residents' cash resources maintained as a drawing account shall include a ledger accounting (columns for income, disbursments, and balance) for each resident, and supporting receipts filed in chronological order. Each accounting shall be kept current.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 4 resident P&I ledgers were not accurate which poses a potential personal rights risk to persons in care.
POC Due Date: 04/09/2024
Plan of Correction
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Administrator Maxine Kniazeff will make sure all account ledgers and account balances are correct and will review regulation section 87217 with all staff responsible for handling resident funds. A signed statement of acknowledgement and understanding will be emailed to LPA Haley by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5