197609358-12-29-2022-31-AS-ERIS-CMKW28-20221229155355

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609358
Report Date: 12/29/2022
Date Signed: 12/29/2022 03:54:07 PM

Document Has Been Signed on 12/29/2022 03:54 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
N LA & CEN COA AC/SC, 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:	12/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	May Javierto		TIME COMPLETED:	04:00 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 1:35 p.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct a Required Annual/Infection Control inspection. LPA was greeted by Staff May Javierto who was wearing a mask and granted access. May took LPA's temperature and requested LPA fill out self screening questionnaire and to sign-in the visitor log. May called the Administrator. The Administrator stated they were unable to come to the facility due to being sick. LPA informed the Administrator of the purpose of the visit, and the Administrator stated staff May can sign the report. LPA reviewed the Mitigation Plan approved 04/15/2021. The inspection tool was used to complete the visit. At 1:40 p.m. LPA began a physical plant tour of the facility and the following was observed: Infection Control: LPA observed masks, hand sanitizers and gloves available for use in the entry and in the kitchen. LPA observed appropriate infection control signs posted through out the facility. May states facility has a 30 day supply of PPE. LPA observed hand washing signs in bathrooms and trash bins with tight fitting lids. Kitchen: The kitchen was observed by LPA to be clean and the appliances and fixtures functional. LPA found a sufficient amount of two day perishable and seven day non-perishable food supply at the facility. LPA found knives and sharp objects stored in a locked drawer. Cleaners and chemical products are kept under the sink and are kept locked. Properly labeled medications were locked in a cabinet in the kitchen. LPA observed a fire extinguisher in the kitchen area to be fully charged and last serviced 03/30/2022. Common Areas: These included the living room, sitting area and dining area. The common areas were clean, clear of clutter and properly furnished. There is a designated laundry room which leads to the attached garage. The laundry room was unlocked and the door leading to the garage where the detergent is kept was locked inaccessible to residents in care.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA DE SOFIA RETIREMENT HOME	FACILITY NUMBER: 197609358
	VISIT DATE: 12/29/2022

NARRATIVE

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Bedrooms: There are a total of five (5) bedrooms, one (1) of which is currently vacant, and one (1) is a shared room designated for residents. All bedrooms were clean, properly furnished and had appropriate bedding and linens. LPA toured a private resident's bedroom and staff #2 (S2) informed LPA the bathroom was a designated staff bathroom and their bedroom was accessed through the staff bathroom. LPA observed no other entry to the S2's bedroom or designated staff bathroom. S2 has personal items and a mattress in the walk-in closet of the resident's private bedroom.

Bathrooms: There are three (3) bathrooms, one (1) of which is designated for staff use located in a residents bedroom. All bathrooms were clean, properly supplied with hand soap, paper towels, grab bars and shower mats. Hot water temperature was measured at 115.7 degrees Fahrenheit.

Surrounding Grounds: There was furniture appropriate for outdoor use and no visible hazards. Covered shaded areas were observed. All passageways were free of obstruction. LPA observed a side gate closed an unlocked. LPA observed a shed in the backyard being used as storage space by the owner.

Smoke and Carbon Monoxide Detector: Staff tested the smoke and carbon monoxide detector at 2:04 p.m. LPA observed detectors to be operational.

Deficiency issued during this visit. Appeal rights provided. Exit Interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 12/29/2022 03:54 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
N LA & CEN COA AC/SC, 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: 12/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(a)(2)(C)

87307(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in using a residents private bedroom as a passageway to the designated staff bathroom and staff bedroom which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/02/2023
	Plan of Correction
1 2 3 4	Administrator will remove S2's personal items and bed from walk-in closet and no longer designate the resident's private bathroom as a staff bathroom. Administrator will submit to LPA a picture of the walk-in closet and bathroom when finished by POC due date 01/02/2022

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC809 (FAS) - (06/04)

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