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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440415
Report Date: 02/24/2022
Date Signed: 02/24/2022 05:19:15 PM


Document Has Been Signed on 02/24/2022 05:19 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:VILLA BOARD AND CARE HOMEFACILITY NUMBER:
071440415
ADMINISTRATOR:VILLA, DANIEL D.FACILITY TYPE:
740
ADDRESS:831 CORAL DR.TELEPHONE:
(510) 799-5572
CITY:RODEOSTATE: CAZIP CODE:
94572
CAPACITY:6CENSUS: 5DATE:
02/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:18 PM
MET WITH:Josefina Booker, AdministratorTIME COMPLETED:
05:30 PM
NARRATIVE
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On 02/24/2022 at 3:10 pm LPAs (Licensing Program Analysts) C. Fowler and L. Hall conducted an unannounced case management inspection in regards to a pre licensing for change of ownership. LPAs met with Josefina Booker Administrator.

During inspection, LPAs toured facility with Administrator and observed the following deficiencies;

-At 10:10 am LPAs observed unlocked kitchen drawer that contained knives.
-At 10:23 am LPAs observed medication in unlocked box in the refrigerator.
-At 10:26 am LPAs observed unlocked medication cart with key in lock.
-At 10:27 am LPAs observed water temperature 126.6 degrees F.
-At 10:31 am LPAs observed unlocked scissors in residents room #4.
-At 10:32 am LPA's observed Clorox and toilet bowl cleaner sitting next to the toilet located in bathroom #2
-At:10:39 am LPA's observed medication sitting on top of the dresser in residents room #1
-At 10:41 am LPAs observed insufficient amount of 7-day non-perishable and 2-day perishables in kitchen.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.



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SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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 02/24/2022 05:19 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: VILLA BOARD AND CARE HOME
FACILITY NUMBER: 071440415

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2022
Section Cited

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87705 (f) The following shall be stored inaccessible to residents with dementia:
(1) Knives... constitute a danger to the resident(s). (2) Over-the-counter medication, nutritional supplements or vitamins... cleaning supplies and disinfectants.This requirement was not met as evidence by:
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Based on LPAs observation licensee did not comply with the section cited above by having scissors, knives and medication inaccessable which poses an immediate health and safety risk do to persons in care.
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Type A
02/25/2022
Section Cited

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87309 (a) Disinfectants, cleaning solutions, poisons... items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
(1) Storage areas for poisons... shall be locked.This requirement was not met as evidence by
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Based on LPAs observation licensee did not comply with the section cited above by having Clorox and toilet cleaner inaccessible to residents which poses an immediate health and safety risk do to persons in care
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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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/24/2022 05:19 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: VILLA BOARD AND CARE HOME
FACILITY NUMBER: 071440415

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2022
Section Cited

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87303 (e) Water...shall be maintained as follows:(2) Faucets used by residents for personal care...Hot water temperature controls shall be maintained... temperature of not less than 105 degree F (41 degree C) and not more than 120 degree...This requirement was not met as evidence by:
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Based on LPAs observation licensee did not comply with the section cited above by maintaining water tempature between 105 degree F and 120 degree F which poses an immediate health and safety risk to clients.
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Type B
03/03/2022
Section Cited

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87555 General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement was not met as evidence by.
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Based on LPAs observation licensee did not comply with the section cited above by not maintaining adequate perishable and non perishable food supply which poses a potential health and safety risk to clients
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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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3