197609358-4-29-2022-31-AS-SSTS-CDXTWE-20220429150523

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609358
Report Date: 04/29/2022
Date Signed: 04/29/2022 03:09:08 PM

Document Has Been Signed on 04/29/2022 03:09 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VILLA DE SOFIA RETIREMENT HOME		FACILITY NUMBER:	197609358
ADMINISTRATOR:	GARCIA, NEMIA		FACILITY TYPE:	740
ADDRESS:	4139 TERRA VERDE DRIVE		TELEPHONE:	(661) 265-0146
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93552
CAPACITY:	6	CENSUS: 3	DATE:	04/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Jimmy Infante, Caregiver		TIME COMPLETED:	02:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 11:30am, Licensing Program Analyst (LPA) Shira Stamps arrived at the above facility for an unannounced one (1) year Required visit. LPA was greeted by caregiver Jimmy Infante. All residents were observed in their rooms, watching tv, eating, and or resting. The caregiver called the Administrator at 11:35am. The Administrator stated they were unable to come to the facility due to having a cold. The caregiver informed the Administrator of the purpose of the visit, and the Administrator stated the caregiver Jimmy Infante can sign the report. Infection control: LPA reviewed facility mitigation plan (approved on 04/15/21) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was screened by the Caregiver and asked to sign-in and sanitize/wash hands. A tour of the physical plant was conducted with the caregiver at 11:50 am. The facility has five (5) bedrooms and two (2) bathrooms currently occupying three (3) residents. One (1) bedroom is designated for staff use only. Living and dining At 11:50am, LPA observed the living room, family room, and office to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 75°F. The smoke detectors and carbon monoxide detector were tested and observed to be operational at 12:05 pm. Food Inspection LPA conducted tour at the kitchen around 11:52 am observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. CONTINUED...

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA DE SOFIA RETIREMENT HOME	FACILITY NUMBER: 197609358
	VISIT DATE: 04/29/2022

NARRATIVE

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Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object being locked in a draw and inaccessible to residents in care. LPA observed chemicals and cleaning supplies locked in the cabinet under the sink. At 11:54 am, medications were observed in the locked cabinet. LPA observed the first aid kit and staff and residents’ files locked in the kitchen cabinet. There is one (1) fire extinguishers located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 03/30/22.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident.

Bathrooms
At 11:55 am LPA observed all bathrooms to have non-skid matts, grab bars, trash cans with lids, and the appropriated wash your hands signs posted. Hot water was tested at 12:03pm and measured within regulation at 118.2 degrees F.

Laundry
LPA observed no chemicals/hazardous items located in laundry room.

Garage
At 11:56 am, LPA observed the garage to be attached to the facility and currently being used for storage, an extra freezer, and chemicals/cleaning supplies. The garage is locked at all times and inaccessible to residents in care.

Physical environment
LPA toured the outside area of the facility at 12:01 pm. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA observed a locked shed used for personal use by the owner. No bodies of water on the premises.

CONTINUED...

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC809 (FAS) - (06/04)

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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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA DE SOFIA RETIREMENT HOME	FACILITY NUMBER: 197609358
	VISIT DATE: 04/29/2022

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Administrative: LPA reviewed personnel records at 12:05pm. Upon review of the personnel records no transfer request was found on file for current staff members Jimmy and Janet Infante. LPA used the Guardian system to verify staff were fingerprint cleared and associated to the facility. LPA was unable to find present staff’s names listed on the facility roster in the Guardian system. LPA made contact with the Regional Office and spoke to her supervisor. The supervisor ran staff’s names through the licensing information system, and found that staff are fingerprint cleared, however not associated to the facility and no transfer request was received. The Administrator stated she will send the Resident Roster and LIC.500 since the caregiver could not find where the documents were located. Annual fee is current. LPA collected the LIC 9182 from both staff members and a copy of their ID.

An exit interview was conducted, citation and civil penalties issued. A copy of this report and appeal rights were given to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC809 (FAS) - (06/04)

Page: 4 of 4

Document Has Been Signed on 04/29/2022 03:09 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA DE SOFIA RETIREMENT HOME	FACILITY NUMBER: 197609358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(c)

87355(c) Criminal Record Clearance A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of the guardian system, review of personnel files, and review of the licensing information system, the licensee did not comply with the section cited above in that two staff members (Jimmy Infante and Janet Infante) are fingerprint cleared however are not associated to the facility and no transfer request was found, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/30/2022
	Plan of Correction
1 2 3 4	The Licensee shall submit a request for Criminal Background Transfer (LIC9182) for staff Jimmy Infante and Janet Infante. A clear copy of staff's picture ID shall be attachted.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Shira Stamps	TELEPHONE: (818) 669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022

LIC809 (FAS) - (06/04)

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