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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005931
Report Date: 04/15/2024
Date Signed: 04/15/2024 12:58:08 PM

Document Has Been Signed on 04/15/2024 12:58 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VA & C HOMES / TERANIMARFACILITY NUMBER:
306005931
ADMINISTRATOR/
DIRECTOR:		AU, ANTHONYFACILITY TYPE:
735
ADDRESS:3034 W. TERANIMAR DRTELEPHONE:
(714) 952-9641
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 6CENSUS: 6DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Maxine KniazeffTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analysts (LPA) Michael Tea and Rose Ruppert and Licensing Program Manager (LPM) Alisa Ortiz conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit and was greeted and granted entry by Teotima Apostol. LPAs and LPM met with Maxine Kniazeff, the Administrator.

For today’s visit, LPAs observed a total of 6 residents in care, 5 were present. LPA observed 2 staff members on duty.

LPAs observed the Administrator's Certificate for Maxine Kniazeff which expires on 07/28/2024. LPAs observed the PUB475 “See Something Say Something” poster was located and posted at the home entry way.

LPAs Tea and Ruppert and LPM Ortiz toured the interior and exterior portions of the facility with Teotima Apostol. The facility is a 2 level structure and is licensed for 4 ambulatory and 2 non-ambulatory residents, For this visit, there are a total of 6 residents in care.

There are a total of 7 bedrooms, of which are 6 private resident rooms, 1 used for storage. LPA toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 3.5 restrooms for residents. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor .

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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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Document Has Been Signed on 04/15/2024 12:58 PM - It Cannot Be Edited


Created By: Michael Tea On 04/15/2024 at 12:01 PM
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: VA & C HOMES / TERANIMAR
FACILITY NUMBER: 306005931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs Tea and Ruppert and LPM Ortiz observation, the licensee did not comply with the section cited above in one out of four toilets had a cracked toilet tank cover which poses safety risk to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
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Licensee will fix the crack or replace the toilet cover and take picture and send the proof.
Type B
Section Cited
CCR
80022(e)(4)
Plan of Operation
(e) If the licensee intends to admit or care for one or more clients who rely upon others to perform all activities of daily living, the plan of operation must also include a statement that demonstrates the licensee's ability to care for these clients. The evidence of ability may include but not be limited to: (4) Documentation of training the licensee and/or staff have completed specific to the needs of these clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's record review, the licensee did not comply with the section cited above in four out four personnel files did not show amount of training which poses safety risk to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
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Licensee will send record of staff training.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2024 12:58 PM - It Cannot Be Edited


Created By: Michael Tea On 04/15/2024 at 12:01 PM
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: VA & C HOMES / TERANIMAR
FACILITY NUMBER: 306005931

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(f)(1)
Other Provisions
(f) A facility shall have both of the following in place: (1) An evacuation chair at each stairwell in a residential facility serving adults, on or before July 1, 2021.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs and LPM's observation the licensee did not comply with the section cited above in not having an evacuation chair which poses/posed a potential safety risk to persons in care.
POC Due Date: 04/22/2024
Plan of Correction
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Licensee will order and provide proof of purchase.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Alisa Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024


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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VA & C HOMES / TERANIMAR
FACILITY NUMBER: 306005931
VISIT DATE: 04/15/2024
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mats were provided. Water temperature in restrooms were measured to be at 108.6 to 109.7 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were located in kitchens and were observed to be locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located upstairs and by the garage entrance.

LPA observed the emergency disaster and evacuation plan, which is posted in the facility hallway. Facility had back-up emergency food and water supply, located in a storage by the kitchen. LPAs observed that First Aid Kit had all the required components. LPAs observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA observed patio furniture under shading, and the grounds were free of any hazards. There are 2 gates in the backyard, which 2 were self-closing and self-latching. No bodies of water were observed.

For today's visit 3 deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. 3 citations were issued.
An exit interview was conducted with Maxine Kniazeff. A copy of this report was provided and explained
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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