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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209292
Report Date: 01/12/2024
Date Signed: 01/12/2024 04:09:48 PM


Document Has Been Signed on 01/12/2024 04:09 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:CAMILA CARE VILLA IIFACILITY NUMBER:
157209292
ADMINISTRATOR:PANGILINAN, MARIA EMMAFACILITY TYPE:
740
ADDRESS:816 LOCH LLOYD LANETELEPHONE:
(904) 762-5945
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY:6CENSUS: 5DATE:
01/12/2024
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
02:41 PM
MET WITH:Maria Emma PangilinanTIME COMPLETED:
04:30 PM
NARRATIVE
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On 1/12/24, Licensing Program Analyst (LPA) M. Medina arrived at the facility to complete the required 10-day complaint visit and observed the following during facility tour and review of facility records:

Staff 1 (S1) and Staff (S2) are fingerprint cleared and not associated to facility but were observed working during facility visit.

Resident rooms for R2 and R3 contained half bed rails, Resident room for R4 contained full bed rails. Residents in these rooms are not on hospice or do not have a physician order with an exception from the department.

During interview with Licensee for complaint, facility was not able to show any record of incident report being sent to department for a fall on 12/24/23 for R1.

Based on today’s visit, deficiencies are being cited in accordance with Title 22 on the attached LIC 809D for the date of 1/12/2024. An immediate civil penalty is being assessed.

An exit interview was conducted with Licensee, Maria Emma Pangilinan, signed on site and a copy of this report, LIC 9098 Proof of Correction and Appeal rights were provided during visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
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


Document Has Been Signed on 01/12/2024 04:09 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: CAMILA CARE VILLA II
FACILITY NUMBER: 157209292

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/13/2024
Section Cited
CCR
87355(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or ***This was not met as evidenced by S1 and S2 are working, fingerprinted, cleared and not associated to facility.
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Licensee to submit LIC 9182 Fingerprint transfer request to Fresno CCL office by POC due date.

Type A
01/13/2024
Section Cited
CCR
87608(a)(5)(A)(B)

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(a) Based on the individual's preadmission appraisal...Postural supports may be used under the following conditions.(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.***This was not met as evidenced by R2 and R3 have 1/2 bed rails, R4 has full bed rails.
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Licensee to submit by POC due date a phsyican order for R2 and R3 having 1/2 bed rails. If R4 is not eligible for hospice evaluation to retain full bed rails, seek physician order for 1/2 bed rails and remove full bed rails.
Type B
01/19/2024
Section Cited
CCR87211(a)(1)

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(a) Each licensee shall furnish to the licensing agency...(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 of any of the events specified in (A) through (D) below. ***This was not met as evidenced by facility was not able to show any record of incident report being sent to department for a fall on 12/24/23 for R1.
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Licensee to submit LIC 624 to Fresno Regional Office by POC due date.

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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: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
LIC809 (FAS) - (06/04)
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