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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609899
Report Date: 01/29/2025
Date Signed: 01/29/2025 03:22:37 PM

Document Has Been Signed on 01/29/2025 03:22 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 VILLAFACILITY NUMBER:
197609899
ADMINISTRATOR/
DIRECTOR:		CAJAYON, JOJOFACILITY TYPE:
740
ADDRESS:44334 LIVELY AVETELEPHONE:
(818) 913-2188
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
01/29/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:44 AM
MET WITH:Dulce Villeros (Caregiver)TIME VISIT/
INSPECTION COMPLETED:
03:36 PM
NARRATIVE
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At 9:40 a.m.,Licensing Program Analyst (LPA) Evelin Rios met with caregiver Dulce Villeros. At approximately 10:15 a.m. LPA spoke to the administrator Jojo Cajayon by telephone and explained the purpose of the visit was to continue the annual visit. An entrance interview was conducted.

On 01/28/2025 LPA initiated required annual visit. Due to time constraints LPA was unable to complete the annual visit. Today LPA will complete the annual visit. LPA could not locate Infection Control Plan for facility but did find records a Mitigation Plan Report was approved on 02/16/2021.

On 01/28/2025 LPA started to review five (5) of five (5) resident records and did not yet review medications and medication records. On 01/29/2025 at 9:59 a.m., LPA continued to review resident records. Resident #6's (R6's), Physician's Report (LIC 602A) revealed they are bedridden. LPA's review of facility sketch on file with Community Care Licensing Division (CCLD) and sketch posted on the facility walls indicate bedroom #6 is designated as a non ambulatory room and bedroom #3 is designated as the bedridden room. On 01/28/2024 at 3:31 p.m. LPA interviewed R6 and they informed LPA they could reach for items but needed assistance to reposition to the left or right. LPAs telephone call with the administrator, revealed they believed the inspector that conducted the fire clearance visit had indicated any room in the facility with a door was cleared for a bedridden resident. LPA review of the Fire Safety Inspection Request (LIC850) indicated the facility does have a capacity for one (1) bedridden resident without indicating which room is designated to house bedridden resident and without the comment that any room may be used to house the one (1) bedridden resident. Administrator agreed to submit required documentation to change status designation of bedroom #6.

LPA spoke with Administrator regarding missing bed rail orders for three (3) out of five (5) residents. Administrator indicated they would obtain orders from family members. LPA advised it must be a written order from a physician. Administrator informed LPA they would be removing bed rails until an orders were obtained. (Continue to LIC809-C)

Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104
DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2025
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 10
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: 01/29/2025
NARRATIVE
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(Continued from LIC809 Case Management Annual Continuation)

At 11:02 a.m. LPA reviewed medication and medication records of five (5) out of (5) five residents. LPA observed the following:

  • Resident #1's (R1's), Medication Administration Record (MAR) did not have records indicating they were given 26 pills out of a 30 quantity PRN medication.
  • Resident #2's (R2's), MAR for December 2024 and January 2025 did not have two medications listed. Medications were observed in resident's medication bin with other prescribed medication.
  • Resident #4 (R4), has one medication labeled to give 2 times daily, review of Medication Administration Record (MAR) only indicated staff were providing it one time at 8 p.m. Staff stated they provide it twice daily.

At 11:38 a.m. LPA spoke to the administrator by telephone and went over medication and medication record concerns. Administrator stated they did not have written orders from a physician for medication for four (4) out of five (5) residents. LPA also discussed with administrator that staff indicated they poured medication running low from one medication to the new medication bottle with start date 02/01/2025.

Deficiencies cited on todays visit (refer to LIC809-D). Immediate Civil Penalty Assessed on todays visit (refer to LIC421IM). Technical Violations issued. Exit interview conducted. Appeal rights provided. Copy of report provided.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC809 (FAS) - (06/04)
Page: 2 of 10
Document Has Been Signed on 01/29/2025 03:22 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: 01/29/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in one (1) medication for resident #1 (R1) that had medication label altered with no documentation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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Administrator will immediately provide medication with prescription labels only and as indicated on the original prescription label until they obtain medication orders for all residents. Administrator will submit a statement of understanding for the regulation cited and that they reviewed facility's own medication policy and provide statement to LPA by POC due date.
Type A
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in one (1) resident, resident #1(R1) was provided PRN medication but had no record of PRN medication given which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2025
Plan of Correction
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Administrator will immediately have staff record when PRN medication is given to resident. Administrator will conduct in-service training for all staff responsible for assisting residents in medication administration. A copy of training material used and sign in sheet of all staff that participated will be submitted to LPA by 02/07/2025.
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 MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104

DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025

LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 01/29/2025 03:22 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: 01/29/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review, the licensee did not comply with the section cited above in one bedridden resident, resident #6 (R6) residing in a bedroom designated by facility sketch to be for non ambulatory resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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Administrator will move resident to bedroom #3(R3) as that room is designated for bedridden by POC due date. Administrator stated they would submit LIC 200 and facility sketch to designate bedroom #6 and bedridden room or to have inspector add comment that any bedroom is cleared to house the one bedridden resident.
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in R3 is on hospice has full bed rail but only has a half bed rail written order, R4 has half bed rail with no written order, R6 is not on hospice and has a full bed rail with no written order, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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Administrator agreed to remove bed rails from three (3) out of five (5) residents and place a half bed rail for R3 until a written order from a physician can be obtained indicating the need for postural support.
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 MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104

DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2025

LIC809 (FAS) - (06/04)
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