197609358-5-5-2024-31-AS-JGTN-D4YR3J-20240505124001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609358
Report Date: 05/05/2024
Date Signed: 05/05/2024 12:40:15 PM

Document Has Been Signed on 05/05/2024 12:40 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
WOODLAND HILLS S.ASC, 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: 4	DATE:	05/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Rodalyn Geraldino - Staff		TIME COMPLETED:	12:45 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	Licensing Program Analyst (LPA) Gary Tan initially met staff Rodalyn Geraldino for a One (1) Year Required visit for this facility. Ms. Geraldino called the administrator Charesa Reyes and explained the reason for the visit. The Administrator designated Ms. Geraldino to sign the report. A tour of the physical plant was conducted at 9:24 AM and the following was noted: There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside and inside. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. The facility has five (5) bedrooms and three (3) bathrooms currently occupying four (4) residents. There is one (1) additional room being used as an office/staff room. The facility is fire cleared for six (6) non-ambulatory residents, (6) one (1) of which may be bedridden. Hospice waiver for two (2). Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 74°F. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide installed at the facility. Fire extinguisher is located in the kitchen and observed to be full and current. The facility is equipped with sprinkler system. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The swimming pool is appropriately fenced and observed to be locked. (continued on LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2024

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: VILLA DE SOFIA RETIREMENT HOME	FACILITY NUMBER: 197609358
	VISIT DATE: 05/05/2024

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
26
27
28
29
30
31
32

(continued on LIC 809-C)

The Garage has access from the inside through the laundry room. The garage was observed to be locked. It is also currently being used as a frozen food, PPE and old equipment storage. Laundry room is located along the bedroom hallway. Laundry detergents, cleaning agents and other toxins are stored in a locked in the garage. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. Cleaning solutions are kept locked in a cabinet under the sink. Backyard has shaded area and outdoor furniture for clients to use. There is also a locked toolshed in the backyard.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured at a range of 113.7°F to 115.1°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. There is a complete first aid kit located in the kitchen.

Client records: Client records are reviewed. One (1) out of four (4) Client records reviewed did not have physician's report on file.
Staff records: LPA conducted a complete file review of staff records. Staff records appeared to be complete and updated. Disaster drill - There was no disaster drill on file. Required posting observed in facility (complaint hot line poster).

Citation issued. Appeal rights discussed and given.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 05/05/2024 12:40 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
WOODLAND HILLS S.ASC, 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: 05/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review, the licensee did not comply with the section cited above in 1 out of 4 residents did not have LIC 602 on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2024
	Plan of Correction
1 2 3 4	The administrator agreed to obtain a medical assessment for R1 and submit a copy to CCLD on or before the POC date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's record review the licensee did not comply with the section cited above as there was no disaster drill on file during visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/13/2024
	Plan of Correction
1 2 3 4	Administrator agreed to conduct a disaster drill and submit proof of training to CCLD on or before the POC date.

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: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3