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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336410193
Report Date: 04/20/2023
Date Signed: 04/20/2023 03:58:33 PM

Document Has Been Signed on 04/20/2023 03:58 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VANDELON HOMECARE INC. IIFACILITY NUMBER:
336410193
ADMINISTRATOR:HAIDE L. UYFACILITY TYPE:
740
ADDRESS:1365 E. WHITTIER AVE.TELEPHONE:
(951) 791-0061
CITY:HEMETSTATE: CAZIP CODE:
92543
CAPACITY: 6CENSUS: 6DATE:
04/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Haide L. Uy, AdministratorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection on March 30, 2023. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility with LPA identification and business card.

Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured at 119-120 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the garage. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications. LPA verified there is a telephone working at this location. LPA interviewed five (5) residents and three (3) staff. Due to time constraints, Inspection will need to be concluded at another time. The following domains were completed today: Infection Control, Operational Requirements, Physical Plant & Environmental Safety, Planned Activities and Food Services completed.

Based on the information received during this visit today, no deficiency being cited per Title 22, Division 6 of The California Code of Regulations. This report was reviewed with and a copy provided to the facility representative.



On this day, April 20, 2023, LPA Delgado arrived unannounced to complete the annual inspection.

Resident record review began. Two (2) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. (Continued on LIC809-C)
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE: DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/30/2023
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 3
Document Has Been Signed on 04/20/2023 03:58 PM - It Cannot Be Edited


Created By: Yolanda Delgado On 04/20/2023 at 03:12 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VANDELON HOMECARE INC. II
FACILITY NUMBER: 336410193

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in emergency drills are not being conducted and documented quarter to quarter which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2023
Plan of Correction
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Administrator will create and place a reminder to conduct diaster drills quarterly and will document the date, time and all staff in attendance of drill and place in drill folder for the faclility. Administrator will submit proof via email to LPA by POC due date,
Type B
Section Cited
HSC
87203
Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Delgado's observation, interview and record review, the licensee did not comply with the section cited above in LPA observed cabinets outlining a makeshift room, with two beds and bedroom furniture inside the makeshift room inside the garage and it is not on the floor plan for the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/04/2023
Plan of Correction
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Administrator will remove makeshift room inside the garage and submit proof of pictures via email to LPA by 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:Jazmond D Harris
LICENSING EVALUATOR NAME:Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2023


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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VANDELON HOMECARE INC. II
FACILITY NUMBER: 336410193
VISIT DATE: 04/20/2023
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(CONTINUED FROM LIC809)

Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized.

LPA began review of employee records. Two (2) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current.

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the garage has temporary walls with two beds and bedroom furniture and it is not on the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 3/30/2023. The facility is conducting emergency disaster drills however not quarter to quarter. The last disaster drill was conducted on 02/26/2023. All domains have been completed.

Based on the information received during this visit today, there were two (2) deficiencies is being cited per Title 22, Division 6 of The California Code of Regulations.

This report, 809-D, and Appeal Rights was reviewed with and a copy will be emailed and a confirmed receipt will be requested by the facility representative.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Yolanda Delgado
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023
LIC809 (FAS) - (06/04)
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