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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440415
Report Date: 01/17/2024
Date Signed: 01/17/2024 05:14:40 PM

Document Has Been Signed on 01/17/2024 05:14 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: 2DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:DANIEL VILLA, ADMINISTRATORTIME COMPLETED:
06:00 PM
NARRATIVE
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On 1/17/2024 at 9:30AM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Daniel Villa and explained the purpose of the visit. The Administrator currently holds a certificate (#6035480740) that expired on 2/7/2023. The facility’s fire clearance was approved for six (6) non-ambulatory residents.

LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of three (3) bedrooms occupied by residents, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 128.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 03/2/2022. Emergency Disaster Plan was not posted or provided. First aid kit was observed to be incomplete.

LPA reviewed Administrator and two (2) staff files which were all incomplete.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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 13
Document Has Been Signed on 01/17/2024 05:14 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/17/2024 at 01:36 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
, 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: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

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 by having the hot water temperature at 128.5 which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/18/2024
Plan of Correction
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Administrator agreed to lower hot water heather, do a video of water being checked and submit to CCLD by POC date.
Type A
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 by having bar cleaner, stone cleaner, razor blade, mini saw, large saw, bernzomatic, propane, febreze air freshener, vitamins, syeringe, insulin, unlocked and assessable which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/18/2024
Plan of Correction
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Administrator agreed to lock all items and make them in assessable to residents in care and submit photos to CCLD by POC date. Cleared during visit.
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 Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 01/17/2024 05:14 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/17/2024 at 01:36 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
, 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: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 having a broken dish washer, spider webs on the walls in the living room, the living room window, and hanging from the ceiling, brown drippings coming down the wall in the living room, tables with dust, closet doors in bedroom #3 off track paperwork on dining table boxes on the floor in the passage way which poses a potential health and safety risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Administrator agreed to repair/replace broken dish washer, and to clean spider webs on the walls in the living room, the living room window, and hanging from the ceiling, brown drippings coming down the wall in the living room, tables with dust, fix closet doors in bedroom #3 and remove paperwork on dining table and boxes on the floor in the passage way and provide CCLD with photos by POC date.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

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 by having a broken knob in the 2nd bather shower, floor of the 2nd bathroom shower has stains, hair in the drain which poses a potential health and safety risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Administrator agreed to fix broken knob in shower #2 and clean the stains and hair from the shower. and submit photos to CCLD by POC 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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 01/17/2024 05:14 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/17/2024 at 01:36 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
, 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: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)(2)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens.

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 by having syringe needles in a container in the small room next to the dining area which poses a potential health and safety risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Administrator agreed to get rid of syringes and read and understand regulation and submit self certification to CCLD by POC date.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 by having 2 large boxes in the door ways which poses a potential health and safety risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Administrator agreed to move 2 large boxes out of the passageway and submit photos to CCLD by POC 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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 01/17/2024 05:14 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/17/2024 at 01:36 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
, 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: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not renewing Administrator and staff CPR or First Aid certification which poses a potential health and safety risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Administrator agreed to get CPR/First Aid renewed and send a copy of updated CPR/First Aid to CCLD via email by POC date.
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not having the Administrator continuing education or recertification documents which poses a potential health and safety risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Administrator agreed to provide CCLD a copy of Administrator recertification document via email by POC 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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 01/17/2024 05:14 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/17/2024 at 01:36 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
, 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: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not providing staff training which poses a potential health and safety risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Administrator agreed to read understand regulation, provide staff with training's and send a copy of self certification and training documents to CCLD by POC date.
Type B
Section Cited
HSC
1569.267(d)
Resident's Bill of Rights
(d) The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not providing staff with ongoing training which poses a potential health and safety or risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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Administrator agreed to read understand regulation, provide staff with training's and send a copy of self certification and training documents to CCLD by POC 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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
Page: 6 of 13
Document Has Been Signed on 01/17/2024 05:14 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/17/2024 at 01:36 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
, 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: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having spider webs with a spider in the kitchen sink area which poses a potential health and safety risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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2
3
4
Administrator agreed to clean and remove spider and spider web from the kitchen sink area and send photo to CCLD via email by POC date.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above not having a copy of the facilities emergency and disaster plan posted or on file which poses a potential health and safety risk to persons in care.
POC Due Date: 01/31/2024
Plan of Correction
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2
3
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Administrator agreed to provide CCLD a copy of the facilities emergency and disaster plan via email by the POC 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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
Page: 7 of 13
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
VISIT DATE: 01/17/2024
NARRATIVE
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CONTINUE FROM LIC 809

LPA observed the following deficiencies:

· At 10:00am, LPA observed scissors on the kitchen counter.
· At 10:05am, LPA observed bar cleaner, stove cleaner, stone cleaner in unlocked cabinet underneath kitchen sink.
· At 10:10am, LPA observed staff medications (insulin)in the refrigerator, razor blade in a unlocked drawer.
· At 10:13am, LPA observed the dishwasher door held together with rope.
· At 10:17am, LPA observed febreze underneath unlocked cabinet underneath bathroom sink and in the hallway on a cabinet and in 2nd bathroom.
· At 10:22am, LPA observed hot water temperature at 128.5 degrees F.
· At 10:28am, LPA observed not enough meat in 1st or 2nd freezer.
· At 10:35am, LPA observed fire extinguisher was expired.
· At 10:40am, LPA observed spider webs over the kitchen sink, on the walls in the living room, hanging from the ceiling, dusty furniture, spills running down the wall at the entry in the living room.
· At 10:47am, LPA observed closet doors off track.
· At 10:50am, LPA observed bathroom shower knob broken and needs to be cleaned.
· At 11:00am, LPA observed a man living in the garage.
· At 11:15am, LPA observed paint, weight bench with weights, tire, bike parts, tire, box, wood planks, lawn mower, 2 ladders, shovel, butain fuel, 2 dollies, unlocked shed, fruit picker, black plastic bags, and a small makeshift building in the back and side yard.
CONTINUE ON LIC809C
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 10 of 13
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
VISIT DATE: 01/17/2024
NARRATIVE
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CONTINUE FROM LIC809

· At 11:20am, LPA observed unlocked medication multi vitamin, vitamin E, D3 and used syringes in small extended room off of the dining area.
· At 11:29am, LPA observed a mini chainsaw, large saw, 2 cans of bernzomatic, and 2 cans of propane located in the dining area.
· At 11:50am· At 11:00am, LPA observed staff and resident files incomplete, facility has no disaster plan.
· At 12:05pm, LPA observed all staff CPR/FIRST AID has expired.

LPA requested the following documents to be submitted to CCLD by 1/25/2024.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance
  • Infection Control Plan

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.


Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC809 (FAS) - (06/04)
Page: 11 of 13
Document Has Been Signed on 01/17/2024 05:14 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/17/2024 at 03:46 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
, 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: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in having 7-day non-perishable which poses a potential health and safety risk to persons in care.
POC Due Date: 01/24/2024
Plan of Correction
1
2
3
4
Administrator agreed to purchase food (meat)and submit receipts and photos of food to CCLD by POC date.
Type B
Section Cited
CCR
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
1
2
3
4
This requirement was not met as evidenced by expired fire extinguisher which poses a potential health & safety risk to residents in care.
POC Due Date: 01/24/2024
Plan of Correction
1
2
3
4
Administrator agreed to provide CCLD with a copy of purchase receipt for new fire extinguisher or service tag from fire extinguisher. Administrator also agreed to have fire extinguisher inspected annually for fire safety compliance.
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 Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
Page: 12 of 13
Document is an Amendment of Original Document on 02/15/2024 01:00 PM


Created By: Carol Fowler On 01/17/2024 at 03:53 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
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: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(A)(7)
87208((A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7)Sketches, showing dimensions, of the following:

This requirement was not met as evidence by:

Deficient Practice Statement
1
2
3
4
Based on LPAs observation licensee did not comply with the section cited above by staff/family sleeping in the garage in a makeshift bedroom being used for accommodation. Which poses a potential health and safety risk to residents.
POC Due Date: 01/31/2024
Plan of Correction
1
2
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4
Administrator agreed not to allow staff/family to sleep in the garage. Facility will submit a written addendum to their operating plan describing how the garage will be utilized as intended to CCLD by POC date.
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:Bennett Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


LIC809 (FAS) - (06/04)
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