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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608379
Report Date: 12/20/2023
Date Signed: 12/20/2023 12:02:59 PM


Document Has Been Signed on 12/20/2023 12:02 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245



FACILITY NAME:AVENIDA VILLA, INC.FACILITY NUMBER:
197608379
ADMINISTRATOR:PHILLIP ROMEROFACILITY TYPE:
740
ADDRESS:1803 AVENIDA FELICIANOTELEPHONE:
(310) 930-6455
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 6DATE:
12/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH: Licensee Zenaida BunagTIME COMPLETED:
12:00 PM
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On 12/20/2023 at 10:00 AM, Licensing Program Analyst(LPA) Lizeth Villwgas conducted an unannounced annual inspection visit using the CARE Inspection Tool. the LPA met with Licensee Zenaida Bunag as the purpose of the visit was explained. The facility is licensed for six residents age 60 and over of which (5) non-ambulatory residents, (1) bedridden, and with (2) hospice waivers. Currently census is 6, facility fees are up to date and liability insurance is active with expiration date of 07/16/2024.

The facility is a single-story structure located in a residential neighborhood and consists of the following: (5) resident bedrooms, (2.5) resident bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area and an extra refrigerator, front yard, backyard with umbrella with table and chairs. No weapons are stored in the premises, no bodies of water. A supply of perishable and non-perishable food was observed. Emergency Water supply is found in the garage. Toxins and knifes were observed to be stored and inaccessible to clients. Last fire drill was on 09/29/23, carbon monoxide and smoke detectors observed and are operational, landline and internet were observed. The facility (2) Fire Extinguishers were checked and found to be fully charged. Exits and walkways are free of debris/hazards.

LPA conducted a records review of 2 staff records, 2 resident records, and 2 medication administration record. No discrepancies observed. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Resident bedrooms were checked, mattresses and box springs were in good condition, adequate lighting, plenty of dresser and closet space was observed. Bathroom toilets and water faucets worked properly, shower was free of mold/mildew, and there are sufficient toiletries accessible to clients. The water temperature properly measured between 105-120 F.. During today’s visit no discrepancies were observed.

Exit interview conducted with Licensee Zenaida Bunag, and a copy of this report was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Lizeth VillegasTELEPHONE: (818) 391-9974
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2023
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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