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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 071440415
Report Date: 03/04/2022
Date Signed: 03/04/2022 12:09:33 PM

Document Has Been Signed on 03/04/2022 12:09 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: 1DATE:
03/04/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Daniel Villa, AdministratorTIME COMPLETED:
12:20 PM
NARRATIVE
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On 3/4/2022 at 10:15 am Licensing Program Analyst (LPA) C. Fowler arrived unannounced to deliver the findings from the Infection Control Inspection conducted on 3/1/2022
LPA met with Administrator, Daniel Villa and explained the purpose of the visit.

LPAs observed the following deficiencies;

-At 2:40pm LPAs observed facility dose not have a Mitigation Plan.
-At 2:49pm LPAs observed unlocked scissors on desk in office/dining room.
-At 2:50pm LPAs observed rakes, shovel, paint, tree trimmer, 3 ladders, lawn mower and unlocked shed in back yard.
-At 2:59pm LPA's observed a hole in the ceiling, no grab bar in bathtub, in shared bathroom, water temperature 129.5 degrees F.
-At 3:04pm LPAs observed bedridden resident with restricted health condition without fire clearance in room #1.

-At 3:05pm LPAs observed a screw driver in the shower to operate the shower faucet in bedroom #1.
-At 3:11pm LPAs observed garage door unlocked. In the garage there was a staff sleeping in a makeshift bedroom being used for accommodation.

Continued on LIC809C.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2022
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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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: 03/02/2022
NARRATIVE
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Continued from LIC809

-At 3:16 pm during record review LPAs observed R1 file was missing Preplacement Appraisal Needs and Services Plan, Identification and Emergency Information, Consent for Medical Treatment and Residents Rights.

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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/04/2022 12:09 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/02/2022 at 09:29 AM
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: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2022
Section Cited
CCR
87303(e)(2)

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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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Administrator agreed to adjust temperature to measure between 105 - 120 degrees F. and submit a photo copy of temperature to CCLD by POC date. Deficiency cleared during visit.
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Based on LPAs observation licensee did not comply with the section cited above by maintaining water temperature between 105 degree F and 120 degree F which poses an immediate health and safety risk to residents.
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Type A
03/05/2022
Section Cited
CCR87705(f)(1)

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(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s)..This requirement was not met as evidence by:
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Administrator agreed to turn the garage doorknob around to lock from the outside. To move tools into the locked garage. To purchase a new lock for the shed and submit photo copies to CCLD by POC date.
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Based on LPAs observation licensee did not comply with the section cited above by not maintaining a safe environment with unlocked rakes, shovel, paint, tree trimmer, 3 ladders, lawn mower and unlocked shed located in the back yard. which poses an immediate health and safety risk to residents.
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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: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/04/2022 12:09 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/02/2022 at 09:41 AM
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: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/11/2022
Section Cited
CCR
87621(b)(1)(B)

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87621(b) In addition to Section 87611 the licensees shall be responsible... (1) Ensuring that ostomy care is provided by an appropriately...(B)There shall be written documentation by an appropriately skilled professional outlining...instruction...facility staff who have been instructed. This requirement was not met as evidence by:
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Administrator agreed to obtain training for staff from an appropriately skill professional and apply for a waver from CCLD, and provide copies to CCLD by the POC date.
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Based on LPAs observation licensee did not comply with the section cited above by accepting a resident with a restricted health condition. Which poses an immediate health and safety risk to clients.
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Type A
03/11/2022
Section Cited
CCR87606(f)(1)

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87606(f)(1) (f) To accept or retain a bedridden person, a facility shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons. This requirement was not met as evidence by:
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Administrator agreed to apply for a fire clearance and update the facilities Plan of Operation and provide a copy to CCLD by the POC date.
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Based on LPAs observation licensee did not comply with the section cited above by accepting a bedridden resident with restricted health condition without fire clearance in room #1. Which poses an immediate 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 Fong
LICENSING EVALUATOR NAME:Carol Fowler
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


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Document Has Been Signed on 03/04/2022 12:09 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/02/2022 at 10:11 AM
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: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2022
Section Cited
CCR
87211(a)(1)

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87211 (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, ... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence,,, This requirement was not met as evidence by:
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Administrator agreed to provide a copy of the Mitigation Plan to CCLD by POC date.
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Based on LPAs observation licensee did not comply with the section cited above by not having a Mitigation Plan LIC 808. Which poses a potential health and safety risk to residents.
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Type B
03/11/2022
Section Cited
CCR87506(b)(17)(A)(B)

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87506(b) Each resident’s record shall contain at least the following ...(17)Documents and information required...(A)Section 87457, Pre-Admission Appraisal;(B)Section 87459, Functional Capabilities;(C) Section 87461, Mental Condition; (D)Section 87462, Social Factors This requirement was not met as evidence by:
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Administrator agreed to complete the resident file and send a copy to CCLD by POC date.
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Based on LPAs observation licensee did not comply with the section cited above by missing required documentation in residents files, Pre-placement Appraisal Needs and Services Plan, Identification and Emergency Information, Consent for Medical Treatment and Residents Rights. Which poses a potential health and safety risk to residents.
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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: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/04/2022 12:09 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/02/2022 at 10:31 AM
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: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2022
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a) 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 was not met as evidence by:
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Administrator agreed to install a grab bar in the bathtub, to get the hole in the ceiling fixed and provide pictures and a copy of the invoice to CCLD by the POC date.
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Based on LPAs observation licensee did not comply with the section cited above by not providing a grab bar in the bathtub. having a hole in the ceiling from an upstairs bathroom leak in the shared bathroom. Using a screwdriver to operate the shower faucet in bedroom #1. Which poses a potential health and safety risk to residents.
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Type B
03/11/2022
Section Cited
CCR87208(A)(7)

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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:
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Administrator agreed not to allow staff 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.
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Based on LPAs observation licensee did not comply with the section cited above by staff sleeping in the garage in a makeshift bedroom being used for accommodation. Which poses a potential health and safety risk to residents.
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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: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


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Document Has Been Signed on 03/04/2022 12:09 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/02/2022 at 11:14 AM
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: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/11/2022
Section Cited
CCR
156.72

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87212 Emergency Disaster Plan
(a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available. This requirement was not met as evidence by:
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Administrator agreed to provide a copy of the facilities Emergency Disaster Plan to CCLD by POC date.
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Based on LPAs observation licensee did not comply with the section cited above by not having an Emergency Disaster Plan. Which poses a potential health and safety risk to residents. which poses a potential health and safety risk to residents.
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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: 03/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2022


LIC809 (FAS) - (06/04)
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