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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 134604737
Report Date: 11/13/2024
Date Signed: 11/13/2024 05:27:29 PM

Document Has Been Signed on 11/13/2024 05:27 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:VILLA ADRIANNAFACILITY NUMBER:
134604737
ADMINISTRATOR/
DIRECTOR:		FERNANDEZ, GUILLERMO RAMIRFACILITY TYPE:
735
ADDRESS:2315 ASHTON CTTELEPHONE:
(442) 270-6587
CITY:IMPERIALSTATE: CAZIP CODE:
92251
CAPACITY: 4CENSUS: 3DATE:
11/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:03 AM
MET WITH:Guillermo Fernandez Administrator TIME VISIT/
INSPECTION COMPLETED:
01:04 PM
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPA Domingo was welcomed by, identified herself to, and discussed the purpose of the visit with Jacqueline Estrada and the Administrator Guillermo Fernandez arrived shortly there after. . 

According to the facility’s license, the facility serves residents age range 18 through 59. Approved fire clearance for four (4) of which, one (1) may be non-ambulatory. Bedroom #1 cleared for non-ambulatory. During today’s inspection, there were a total of three (3) clients in care, and per medical records, all were ambulatory.

LPA, accompanied by licensee’s staff, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows and screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities.  Call box was available in each resident unit and were tested for functionality. Resident's room temperatures were within a comfortable range. The facility’s ambient internal temperature was 72 F. Hot water temperature at taps accessible to clients were all compliant: Kitchen sink was 120 F, Bathroom #1 sink was 118 F.

Refrigerator temperature was 35 F and freezer temperature was -2 F. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking/dining equipment and utensils were present. There were no sharp objects, toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to clients. Medications were labeled, as required, and stored in locked areas.

[CONTINUED ON LIC 809C]
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: VILLA ADRIANNA
FACILITY NUMBER: 134604737
VISIT DATE: 11/13/2024
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[CONTINUED FROM LIC 809]

No pools or bodies of water were observed on the premises. Per the licensee's staff, no firearms or ammunition are kept at the facility. Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were serviced within the last 12 months. First aid kit(s) were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. The last disaster drill was conducted in 10/2024.

LPAs interviewed multiple staff and clients. LPA reviewed multiple staff and client records/files. The interviews did not raise any significant licensing concerns. LPA observed that residents were being treated with dignity by staff, and there were sufficient staff on duty to meet resident’s needs. The reviewed files contained required documents. Confidential records were stored in locked areas. Licensee's staff also presented proof of current/active business liability insurance and surety bond.

No deficiencies were observed or cited during today's annual inspection.

An exit interview was conducted with Guillermo Fernandez, Administrator, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
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