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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005930
Report Date: 04/14/2022
Date Signed: 04/15/2022 08:17:59 AM

Document Has Been Signed on 04/15/2022 08:17 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: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: 5DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:36 AM
MET WITH:Eleanor Kairan- Caregiver/ Administrator- Maxine KniazeffTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA)Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Eleanor Kairan and explained the reason for the visit. At 12:08 PM Assistant Administrator Maxine Kniazeff arrived during the visit.

At 11:38AM, LPA toured the facility with Caregiver Eleanor Kairan. Facility is 5 bedroom, 2 bathroom single story home with a detached garage. Facility has 5 residents present during today's visit. LPA observed residents relaxing in the facility. Facility appears clean and sanitary. All residents rooms had the required elements as well as restrooms stocked with soap/ sanitizer. LPA observed the screening/ sanitizing station in the entrance of the facility. Facility uses a handwritten sign in/ questionnaire. Facility takes residents and staff temperatures daily and documents. LPA observed 7 day supply of emergency food with packs of water. LPA observed locked medication closet. LPA toured the outside grounds and exit gates are unlocked and self latching. Facility has a plan for covid testing residenst and staff as needed as well as a plan for isolation. LPA observed PPE in front of the facility. All staff and residents are vaccinated for Covid-19. LPA reviewed all residents files and all contained required documentation including updated emergency information.


No deficiencies noted during today's visit. Exit interview conducted and a copy of this report was left at the facility
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2022
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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