197609872-9-16-2021-31-AS-APAA-C6WUB9-20210916152558

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609872
Report Date: 09/16/2021
Date Signed: 09/16/2021 03:26:55 PM

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:	ANAVERDES VILLA		FACILITY NUMBER:	197609872
ADMINISTRATOR:	ESTRELLA, ERWIN		FACILITY TYPE:	740
ADDRESS:	37335 PAINTBRUSH DR		TELEPHONE:	(661) 526-7000
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 5	DATE:	09/16/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Erwin Estrella, Administrator		TIME COMPLETED:	03:45 PM

NARRATIVE

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At 12:00 pm Licensing Program Analysts (LPAs) Angela Panushkina, Shira Staps and Licensing Program Manager (LPM) Nichelle Gillyard conducted an unannounced annual inspection at the facility mentioned above. Team was greeted by staff who granted access to the facility. LPA team met with Administrator Erwin Estrella and a physical tour was conducted at 1:05pm and team observed the following:

Infection control: LPA reviewed the facility mitigation plan (approved on 02/14/2021) to make sure licensee was following current infection control recommendations. Upon arrival, staff took LPAs temperatures and was asked to sign-in the visitors’ log and were asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff. Team observed all trash can throughout the facility have fitted lids and protected from cross contamination.

Kitchen: At approximately, 1:10pm LPA team toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Food storage and preparation areas are clean and inaccessible to pests. All knives and sharp objects are locked and inaccessible to residents in care. During inspection, LPAs reminded the Administrator that the locking magnets shall maintain with the staff at all time. At 1:15pm LPAs observed the burner in the middle and right side is not functional on the stove. LPA team reminded the Administrator to clean it and make it functional.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 1:50pm they were tested and observed to be operational

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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: ANAVERDES VILLA	FACILITY NUMBER: 197609872
	VISIT DATE: 09/16/2021

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Resident rooms: All residents bedrooms were properly furnished, had sufficient lighting and appeared to be clean and had appropriate bedding.

Bathrooms: The hot water temperature measured within regulation, at 112°F. LPA observed appropriate hand washing signs posted in each bathroom, grab bars and non-skid mat.

Laundry service: At approximately 1:45pm, LPA team toured through the laundry area and observed cleaning products/chemicals inaccessible to residents.

LPA discussed the importance of maintaining the care and supervision to meet the needs of residents

Medications are centrally stored and locked in the kitchen cabinet and inaccessible to residents in care.

Outside areas: At approximately, 1:30pm LPAs toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents
There are no bodies of water

Administrative: LPA collected Certificate of Liability Insurance, Administrator Certificate and LIC.500. Annual fees are current. Two staff on duty were hired today and had not been fingerprint cleared and/or associated with the facility.

Deficiencies issued per Title 22.

Appeal rights issued.

Exit interview.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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: ANAVERDES VILLA	FACILITY NUMBER: 197609872
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(a)

87355 Criminal Record Clearance (a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review. This requirement is not met as evidenced by This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. 2 staff who started today are not fingerprint cleared and/or associated with the facility which poses an immediate health, safety risk to persons in care.
	POC Due Date: 09/18/2021
	Plan of Correction
1 2 3 4	Administrator has agreed to either have the staff get fingerprinted or submit the request for trinsfer. Administrator will provide an updated LIC500 to reflect new staff.

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: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC809 (FAS) - (06/04)

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