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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609555
Report Date: 06/02/2022
Date Signed: 06/02/2022 03:21:50 PM


Document Has Been Signed on 06/02/2022 03:21 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:B AND B SENIOR VILLAFACILITY NUMBER:
197609555
ADMINISTRATOR:BAINGAN, GLADELYNFACILITY TYPE:
740
ADDRESS:23019 VISTA DELGADOTELEPHONE:
(954) 200-0232
CITY:VALENCIASTATE: CAZIP CODE:
91354
CAPACITY:6CENSUS: 6DATE:
06/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Aileen Sangco, Staff TIME COMPLETED:
03:45 PM
NARRATIVE
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At 11:30am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by Lorena Eusebio, who granted access to the facility and LPA explained the reason for the visit.

At 11:35pm, LPA conducted a tour of the facility and the following was observed:

Infection control: LPA reviewed the facility mitigation plan (approved on 04/11/2021) to make sure licensee was following current infection control recommendations. Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Staff stated they have sufficient PPE supplies for residents and staff. LPA observed all trash can throughout the facility missing lids.

Kitchen: LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents.

Medications: At approximately, 11:40am LPA observed medications are centrally stored and locked in the closet, by the kitchen area and inaccessible to residents in care.



Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational.

Bathrooms: At 11:55am LPA observed all bathrooms are clean and in good repair. Properly supplied with



Continue on LIC809-C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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 6


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: B AND B SENIOR VILLA
FACILITY NUMBER: 197609555
VISIT DATE: 06/02/2022
NARRATIVE
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toilet papers, soap and paper towels. The hot water temperature measured at 108.0°F. LPA observed
appropriate grab bar and non-skid mats. LPA observed appropriate hand washing signs posted in each bathroom.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 12:00pm they were tested and observed to be operational.

Common Areas: The facility maintains a comfortable temperature at 77°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. There is a fire extinguisher by the kitchen area and it was last serviced on 03/05/2020.



Outside areas: At approximately, 12:10pm LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

The garage: Laundry area is located in an attached garage and kept locked and inaccessible to residents. Extra PPE supplies and food storage was also observed.

Administrative: LPA collected Certificate of Liability Insurance and LIC.500.

Following citations Civil Penalty for $500 issued for the identified deficiencies pursuant to Title 22 Regulations on LIC809D.



Exit interview conducted, appeal rights discussed and a copy of this report provided to the Administrator.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 06/02/2022 03:21 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: B AND B SENIOR VILLA
FACILITY NUMBER: 197609555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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ased on observation, the licensee did not comply with the section cited above as the fire extinguisher has not been serviced since 03/05/2020, which poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 06/03/2022
Plan of Correction
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Licensee/Administrator will have fire extinguisher serviced or purchase a new one. Licensee/administrator will submit documentation to confirm servicing of the fire extinguisher or submit photo and receipt confirming purchase of a new fire extinguisher. This is a zero tolerance violation therefore a civil penalty in the amount of $500 dollars has been assessed/issued. Civil Penalty in the amount of $100 dollars per day will continue to accrue until POC has been received.
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and staff interviews, the licensee did not comply with the section cited above by retaining 2 bedridden residents (R2 and R3) without a proper fire clearance (facility is only approved to retain 1 bedridden resident in room #4), which poses an immediate health, safety or personal rights risk to persons in care..
POC Due Date: 06/03/2022
Plan of Correction
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Licensee / Administrator will submit LIC200 and Facility Sketch. Facility sketch will need to specify rooms for bedridden residents. This is a zero tollarance violation, therfore, a civil penalty in the amount of $500.00 has been issued. Civil penatlty in the amounto $100.00 per day will occure until POC is received.

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 GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 06/02/2022 03:21 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: B AND B SENIOR VILLA
FACILITY NUMBER: 197609555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)
Personal Accommodations and Services: 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above by allowing staff to sleep in common area (living room) which poses a potential personal rights risk to persons in care.
POC Due Date: 06/09/2022
Plan of Correction
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Licensee/Administrator will notify the LPA/Department in writing how this deficiency is cleared.
Type B
Section Cited
CCR
87633(b)
A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not maintaining a hospice care plan for 2 out of 2 residents (R1 and R2) who are currently on hospice which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2022
Plan of Correction
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Licensee/Administrator will obtain a current/complete hospice care plan for R1 and R2 and submit copies to the LPA as POC.

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 GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 06/02/2022 03:21 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: B AND B SENIOR VILLA
FACILITY NUMBER: 197609555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(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 requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made the licensee did not comply with the section cited above by utilizing full bedrails for R1 and R2 who are on hospice, however licensee does not have hospice care plan which indicates the need for the rails which poses an immediate health, safety and personal rights risk to persons in care..
POC Due Date: 06/03/2022
Plan of Correction
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Licensee/Administrator will request a current and updated hospice care plan for both residents which indicates the need/doctors order for the full rails. Copy of the Hospice care plans will need to be submitted as POC.
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services:
The following space and safety provisions shall apply to all facilities: All outdoor and indoor passageways and stairways shall be kept free of obstruction. All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations made by LPA on 06/02/22 the facility did not ensure the exit doors in room #1 and #4 were free of obstruciton, which poses an immediate risk to residents in care. .
POC Due Date: 06/03/2022
Plan of Correction
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Licensee/administrator will submit a written statement notifying the department what steps will be taken to clear this deficiency and to ensure such deficiency will not reoccur.

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 GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6


Document Has Been Signed on 06/02/2022 03:21 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: B AND B SENIOR VILLA
FACILITY NUMBER: 197609555

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87632(a)(1)
In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department. The request shall include, but not be limited to the following: (1)Specification of the maximum number of terminally ill residents which the facility wants to have at any 1 time

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, the licensee did not comply with the section cited above by not having an approved hospice waiver but retaining two residents (R1 and R2) who are receiving hospice services, which poses an potential health, safety and personal rights risk to persons in care.
POC Due Date: 06/09/2022
Plan of Correction
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Licensee/Administrator will either submit a request for a hospice waiver increase, or hospice waiver exception.
Type B
Section Cited
CCR
1569.696(a)
All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by not ensuring staff received the required training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/09/2022
Plan of Correction
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Licensee/administrator will schedule vendorized training for all staff. Licensee/administrator will submit verification of scheduled training with the trainers credentials to LPA 06/06/2022 and submit verification of completed training to LPA by 07/01/2022

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 GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
LIC809 (FAS) - (06/04)
Page: 5 of 6