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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107209072
Report Date: 08/04/2022
Date Signed: 08/04/2022 12:56:37 PM


Document Has Been Signed on 08/04/2022 12:56 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:VILLA GUEST HOMEFACILITY NUMBER:
107209072
ADMINISTRATOR:ALEGRE, AMOR A.FACILITY TYPE:
740
ADDRESS:794 N. VILLA AVENUETELEPHONE:
(559) 369-9949
CITY:FRESNOSTATE: CAZIP CODE:
93727
CAPACITY:4CENSUS: 4DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator/Licensee Amor AlegreTIME COMPLETED:
01:15 PM
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On 8/4/2022, Licensing Program Analyst (LPA) K. Kaur arrived unannounced to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was allowed entry by Staff. Administrator/Licensee Amor Alegre was contacted and would be arriving to assist with the inspection.

Facility staff was observed with face coverings. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Social distancing and cough etiquette postings observed in facility. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. At 11:45 PM LPA observed Fire extinguisher in hallway to be expired as of 6/16/2021. Food supply was checked and appeared to be an adequate supply. All resident’s room toured and observed to be adequately furnished and lit throughout. LPA toured bathrooms and observed Trash bins with lids and hand washing signs. Cleaning supplies and chemicals were locked in the office next to the Laundry Room. LPA checked residents’ locked medication in the kitchen cabinet and observed a 30-Day supply of PPE. A small sample of Staff records were reviewed for good health and infection control training. Residents’ records reviewed to have updated emergency contact information.

Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22,
Division 6.

LPA is requesting the following documents be submitted to the Fresno CCL office by 8/11/2022: Current copy
of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan (LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Administrator. Report signed on-site by Administrator and printed copy provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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Document Has Been Signed on 08/04/2022 12:56 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, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: VILLA GUEST HOME
FACILITY NUMBER: 107209072

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203

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 observation, the licensee did not comply with the section cited above in 1 out of 1. Fire extinguisher was expired
with a service date of 6/16/201, which poses an immediate health, safety or personal rights risk to persons in
care.
POC Due Date: 08/05/2022
Plan of Correction
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Licensee to either have fire extinguisher serviced or buy new extinguisher and submit pictures as proof of POC.
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: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: (559) 341-7449
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
LIC809 (FAS) - (06/04)
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