197609899-1-28-2025-31-AS-ERIS-DDD2CC-20250128161631

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609899
Report Date: 01/28/2025
Date Signed: 01/28/2025 04:16:37 PM

Document Has Been Signed on 01/28/2025 04:16 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/ DIRECTOR:	CAJAYON, JOJO		FACILITY TYPE:	740
ADDRESS:	44334 LIVELY AVE		TELEPHONE:	(818) 913-2188
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:28 PM
MET WITH:	Dulce Villeros (Caregiver)		TIME VISIT/ INSPECTION COMPLETED:	04:30 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 01/28/2025 at 1:28 p.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct an unannounced Required Annual Inspection. LPA was greeted by caregiver Dulce Villeros who granted access. Dulce asked LPA to sign in and they sent a text message to the administrator, Jojo Cajayon letting them know LPA was at the facility. Staff #2 (S2) at the facility contacted administrator via telephone and LPA explained the reason for the visit. The administrator could not meet LPA at the facility for todays visit, and designated Dulce to sign today's report. The inspection tool was used to conduct this visit. At approximately 1:35 p.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. LPA observed two residents watching tv in the living area. The dining and living area were clean and clear of clutter. Furniture appeared clean and in good repair. 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 05/15/2024. In the hallway LPA observed the thermostat at a comfortable temperature of 77°F. 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 sufficient amount of 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 staff refrigerator. LPA observed smoke detectors through out the facility that are interconnected and dual carbon monoxide detectors. LPA observed caregiver test the dual smoke/carbon detector at 2:18 p.m. and it was observed to be functioning properly. (Continue to LIC809-C)

Eva Miller	TELEPHONE: (818) 596-4373
Evelin Rios	TELEPHONE: 424-299-6104
	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

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: 01/28/2025

NARRATIVE

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Bedrooms: There six (6) bedrooms designated for resident use. One (1) out of the six (6) rooms is currently vacant. LPA observed a hole on the wall in Room labeled #3. LPA's interview with resident #3 (R3) revealed the hole has been there for at least two days and they believe they had caused it in their sleep. Interview with staff confirms the hole has been there at least a week and it may have been caused by the hospital bed when it is moved. All resident rooms were observed furnished with required lighting, chair, bed, and linens. Exit doors with auditory alarms were working properly at time of visit.

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, and nonskid mats. LPA observed a sufficient supply of hand soup and paper towels. At approximately 3:40 p.m. the hot water temperature in both bathrooms was tested and read between 117.3 and 118.2 degrees Fahrenheit.

Surrounding Grounds: Passageway leading to the side gate exit was free from obstruction. There is appropriate outdoor seating for residents. LPA observed one shed unlocked in the backyard. Shed is being used for facility storage.

Resident, Staff and Facility files: At 2:21 p.m. LPA reviewed two (2) staff files for the staff present at time of visit for compliance with licensing forms. LPA reviewed administrator certification and found their name under the renewal pending list. At approximately 2:45 p.m. LPA contacted the administrator and discussed the LIC610E, Infection Control Plan, and Emergency Disaster Drills. At 2:50 p.m. LPA started to review five (5) out of five (5) resident records.

Due to time restraints, LPA was unable to complete the annual visit at this time. LPA did not complete review of resident records or medication documentation. An unannounced follow-up visit will be conducted at a later date to complete the annual inspection.

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: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/28/2025 04:16 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: 01/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in one resident's wall having a hole on the wall which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/07/2025
	Plan of Correction
1 2 3 4	License will send LPA a picture of the wall after it has been fixed by POC due date.

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.

Eva Miller	TELEPHONE: (818) 596-4373
Evelin Rios	TELEPHONE: 424-299-6104
	DATE: 01/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025

LIC809 (FAS) - (06/04)

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