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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209288
Report Date: 02/19/2025
Date Signed: 02/19/2025 03:32:57 PM

Document Has Been Signed on 02/19/2025 03:32 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CAMILA CARE VILLA, LLCFACILITY NUMBER:
157209288
ADMINISTRATOR/
DIRECTOR:		PANGILINAN, MARIA EMMAFACILITY TYPE:
740
ADDRESS:10005 COBBLESTONE AVETELEPHONE:
(904) 762-5945
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 6DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Maria Emma Pangilinan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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On 02/19/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and requested to meet with. Licensee(L1) Maria Emma Pangilinan. LPA toured facility with L1. All six residents were present during the inspection. Three residents were observed sitting in the living room.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside.

At 10:24AM, medications were checked and observed unlocked medication closet. Residents’ MARS were reviewed. At 12:16PM, tools were observed in kitchen drawer unlock. An adequate supply of perishable and non-perishable food was observed. Sharps and knives observed locked under kitchen sink and in kitchen drawer.

Refrigerator temperature maintained at 38 degrees F and freezer maintained at 0 degree F. Fire extinguisher was observed with a service date of: 12/17/24. Chemicals observed lock in laundry room. Washer and dryer observed functional and operational during visit.

Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are observed with securely fastened grab bars and non-skid mat. Hot water temperature was tested range at 106.3 and 106.5 degrees F in master bathroom and
105.4 degrees F. in bathroom 1.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CAMILA CARE VILLA, LLC
FACILITY NUMBER: 157209288
VISIT DATE: 02/19/2025
NARRATIVE
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Outside of facility toured and observed free of debris. Side gate was self-closing and self-latching. 5 out of 6 residents’ files were reviewed to have all required documents. A sample of staff files were reviewed to have all required documents. Carbon monoxide and smoke detectors were tested and observed to be operational.

Technical Support Program (TSP) assistance was offered to Licensee. Licensee will make a decision and
reach out the department regarding acceptance.


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

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 02/25/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current Administrator Certificate, control of property, and current liability insurance. A copy of this report and appeal rights was provided to Licensee, whose signature on this form confirms receipt of this report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/19/2025 03:32 PM - It Cannot Be Edited


Created By: Mai Yang On 02/19/2025 at 02:49 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CAMILA CARE VILLA, LLC
FACILITY NUMBER: 157209288

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
87465(h)(2) Centrally stored medicines shall be kept in a safe and locked place... not accessible to persons other than employees...

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 when LPA observed at 10:24AM, medications stored in the medication unlock. Licensee checked and confirmed medication closet was not lock which poses/ posed an immediate health, safety or personal rights risk to person in care.

POC Due Date: 02/20/2025
Plan of Correction
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Licensee immediately locked medication cabinet and removed staff medications. POC cleared during visit.
Type A
Section Cited
CCR
87465(c)(3)
87465(c)(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on observation, records reviewed, and interview conducted, R1’s medication Guaifenesin ER 600mg was filled on 02/11/25 has been administered 12 tablets, medication not record in the resident’s MAR. R3’s medication Brimonidine Tart 5ml Sol was administered 02/19/25 at 7AM and not recorded by staff which poses/posed a potential health and safety risk to the resident in care.
POC Due Date: 02/20/2025
Plan of Correction
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Staff immediately recorded in R3’s MAR medication Brimonidine Tart administered. Licensee will submit document of R1’s medication Guaifenesin ER 600mg documented in the MARs to Fresno CCL office by POC due date 02/20/25.
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 Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/19/2025 03:32 PM - It Cannot Be Edited


Created By: Mai Yang On 02/19/2025 at 02:51 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CAMILA CARE VILLA, LLC
FACILITY NUMBER: 157209288

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
Deficient Practice Statement
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Based on records review and observation, R1’s MARs were reviewed, and medications were checked. R1’s medications Metoprolol 50 mg, Memantine 5 mg, Fexofenadine 180 mg, Aspirin 81mg, and Beta Prostate were not accounted for. R2’s medications Mirtazapine 30 mg, Metformin 500mg, Esomeprazole/ Magnesium 20 mg, and Vitamin D2 1.25mg were not accounted for. R2’s medication Mirtazapine 30 mg in the MARs was recorded 15 mg, Metformin Hcl 500mg doctor order take 1 tablet by mouth twice daily was administered and record in R2’s MAR administered daily once daily for the month of February 2025, and GNP stool softener doctor order take 1 tablet by mouth every day as needed and record in R2’s MAR administered once daily for the month of February 2025, which poses an immediate health and safety risk for the person in care.
POC Due Date: 02/20/2025
Plan of Correction
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Licensees agree to write statement of steps facility will take to ensure regulations is met. Statement will be submitted to Fresno CCL by POC due date 02/20/25.

Licensee shall have all staff retrained on medication training which include administering medications, documentation, recording centrally stored medications, and review medications. Licensee will submit documentation of training topics with staff attendance rooster to the Fresno CCL office by 03/04/25.
Type A
Section Cited
CCR
87465(h)(5)
87465(h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 when LPA checked R1’s Potassium medication and observed 12 unknown tablets that were a different stored in the same bottle which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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Licensee immediately removed the 12 unknown tablets out of the Potassium medication bottle. POC 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:See Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


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Document Has Been Signed on 02/19/2025 03:32 PM - It Cannot Be Edited


Created By: Mai Yang On 02/19/2025 at 02:54 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CAMILA CARE VILLA, LLC
FACILITY NUMBER: 157209288

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 (f)(1) Care of Persons with Dementia (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 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 when LPA observed at 12:16PM, tools stored in kitchen drawer under kitchen counter unlock and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2025
Plan of Correction
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Licensee immediately removed tools into lock shelf. POC cleared during visit.
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 Moua
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
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