197609899-1-22-2024-31-AS-ERIS-CZQT55-20240122132457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609899
Report Date: 01/22/2024
Date Signed: 01/22/2024 01:25:07 PM

Document Has Been Signed on 01/22/2024 01:25 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:	ARCADY VILLA		FACILITY NUMBER:	197609899
ADMINISTRATOR:	CAJAYON, JOJO		FACILITY TYPE:	740
ADDRESS:	44334 LIVELY AVE		TELEPHONE:	(818) 913-2188
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 5	DATE:	01/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Jenny Franoso		TIME COMPLETED:	01:30 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	On 01/22/2024 at 9:20 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct a Required Annual Inspection. LPA was greeted by caregiver Jenny Franoso who granted access. Jenny asked LPA to sign in. Jenny called the administrator Jojo Cajayon and LPA explained the reason for the visit. Jojo could not meet LPA at the facility for todays visit, Jojo designated Jenny to sign today's report. The inspection tool was used to complete this visit. At the facility LPA observed two caregivers Jenny and staff #1 (S1). At 9:35 a.m. LPA began a physical plant tour of the facility and the following was observed: Dining / Living Area: LPA observed required postings by the facility entrance. The dining and living area were clean and clear of clutter. Furniture appeared clean and in good repair. A fireplace located in the living area was not in use and secured with a glass screen. In the hallway by the dining area, LPA observed the thermostat at a comfortable temperature of 76°F. Dining table was clean, clear of clutter and sits the capacity of the facility. The fire extinguisher was observed by the dining table fully charged last serviced on 05/26/2023. Kitchen: LPA observed the kitchen to be clean and clear of clutter. Cleaning chemicals are locked under the sink. Knives and sharps are kept locked in a kitchen drawer inaccessible to residents. LPA observed a 2-day perishable and 7-day non-perishable supply of food; properly stored. LPA observed a small refrigerator locked and used for storing medication requiring refrigeration and a second refrigerator by the dining table. LPA observed smoke detectors through out the facility that are interconnected and dual carbon monoxide. LPA observed S1 test the smoke/carbon detectors at 11:07 a.m. and it was observed to be functioning properly. (Continued to LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

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: ARCADY VILLA	FACILITY NUMBER: 197609899
	VISIT DATE: 01/22/2024

NARRATIVE

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Bedrooms: There are seven (7) total bedrooms six (6) bedrooms are designated for resident use. One (1) out of the six (6) rooms is currently vacant. All resident rooms are furnished with required lighting, chair, bed, and linens. Exit doors with auditory alarms where working properly.

Bathrooms: There are two (2) bathrooms designated for resident use. Both bathrooms are accessible to residents by the hallway. Both bathrooms were well lit, clean, had grab bars, had hand washing signs, nonskid mats and trash bins with lids. LPA observed a sufficient supply of hand soup and paper towels. At approximately 11:07 a.m. the hot water temperature in one (1) out of two (2) bathrooms was tested and read 113.1 degrees Fahrenheit.

Surrounding Grounds: Passageways were free from obstruction. Side gate was observed closed but unlocked. There is appropriate outdoor seating for residents with no shade. LPA observed one shed unlocked in the backyard. Shed is being used for storage and has a third refrigerator. LPA observed a hospital bed in the backyard according to administrator bed is scheduled to be picked up for removal.

Resident and Staff files: At 10:15 a.m. LPA reviewed two (2) staff files for the staff present at time of visit and observed both files missing LIC 503 - Health Screening with TB screening. LPA contacted administrator at 11:50 a.m. according to administrator staff have required documentation, however it could not be provided to LPA at time of visit. LPA reviewed five (5) out of five (5) resident records and Resident #4 (R4) was missing a Medical Assessment/ Physician's report and admission agreement was not signed by the facility. Resident #3 (R3) was missing an updated annual medical assessment/ physician's report due to their dementia diagnosis. LPA contacted administrator at 11:50 a.m. to discuss missing and incomplete records. According to administrator they are working with resident's responsible parties to thoroughly complete records.

Medications: LPA observed, resident medications locked in a small refrigerator in the kitchen and looked in a hallway cabinet inaccessible to residents. Medication and Medication Records were reviewed for proper documentation.

Deficiencies cited (refer to 809D). Exit interview conducted. Appeal rights provided. 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: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/22/2024 01:25 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: ARCADY VILLA	FACILITY NUMBER: 197609899
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. 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 in one [1] out of five [5] admission agreements. Resident #4 (R4's) admission agreement was missing the licensee's or facility representative signature which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2024
	Plan of Correction
1 2 3 4	Licensee will review all resident records to ensure records are signed by facility representative and resident or their responsible party. Licensee will submit a copy of R4'a admission agreement signed and dated by facility to LPA by POC due date.

Type B

Section Cited

CCR

87458(a)

87458 (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 record review, the licensee did not comply with the section cited above in one [1] out of five [5] resident records. Resident #4 (R4) was missing a medical assessment / Physician's report prior to admission which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2024
	Plan of Correction
1 2 3 4	Licensee will ensure a Physician's Report / Medical Assessment is completed for R4 and submit a copy to LPA by POC due 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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 01/22/2024 01:25 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: ARCADY VILLA	FACILITY NUMBER: 197609899
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

87705(c)(5) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. 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 in one (1) out of five (5) resident records. Resident #3 (R3) who has dementia did not have an annual required medical assessment/ physician's report on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2024
	Plan of Correction
1 2 3 4	Licensee will ensure an annual medical assessment/physician's report is conducted for R3 and submit a copy to LPA by POC due date.

Type B

Section Cited

CCR

87412(a)(11)

87412 (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. 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 in two (2) out of two (2) staff records reviewed on todays visit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/02/2024
	Plan of Correction
1 2 3 4	Licensee will ensure health screening with TB exams are conducted for each staff. Licensee will submit LIC503 to LPA by POC due 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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

LIC809 (FAS) - (06/04)

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