197610254-5-15-2023-31-AS-ERIS-CRUTK3-20230515144716

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610254
Report Date: 05/15/2023
Date Signed: 05/15/2023 02:47:27 PM

Document Has Been Signed on 05/15/2023 02:47 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:	AMARE VILLA		FACILITY NUMBER:	197610254
ADMINISTRATOR:	LANDICHO, RENELYN		FACILITY TYPE:	740
ADDRESS:	2042 KALLIOPE AVENUE		TELEPHONE:	(661) 878-5085
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 2	DATE:	05/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:43 AM
MET WITH:	Renelyn Landicho		TIME COMPLETED:	03:00 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 05/15/2023 at 9:43 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection. LPA observed appropriate Covid-19 postings on the outside wall by the front door. LPA was greeted by the Administrator Renelyn Landicho and granted access. Administrator requested LPA check temperature on temperature reader affixed to the entry wall and asked LPA to sign in. LPA explained the reason for the visit. At approximately 9:50 a.m. LPA and the administrator toured the physical plant of the facility, and the following was observed. Bedrooms: LPA inspected seven (7) out of seven (7) bedrooms which six (6) are for resident use. Bedrooms are for private use. LPA observed each resident bedroom to be properly furnished with one bed, appropriate night stand, chair, bedding and with sufficient lighting and storage. Bathrooms: The facility has two (2) bathrooms one (1) of which is located in a vacant bedroom. LPA took water temperature from one (1) out two (2) bathrooms. At 10:36 a.m. the temperature from the sink read 113.5 degrees Fahrenheit. LPA observed the bathrooms to be clean and properly supplied with toilet paper, paper towels, hand soap, and trash bins with lids. In the hallway LPA observed linen closets used to store extra PPE and a first aid kit. Laundry/Garage: Laundry room is kept locked and is a passageway to the garage. Detergents are kept locked in a cabinet under the laundry sink. Garage is not accessible to residents. In the garage LPA observed a second fridge with extra food stored for residents. Garage is also used to store extra supplies for residents. (Continued on LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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: AMARE VILLA	FACILITY NUMBER: 197610254
	VISIT DATE: 05/15/2023

NARRATIVE

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(Continued LIC809-C)
Surrounding Grounds: LPA and administrator exited from an emergency exit sliding door located in a vacant bedroom. There is a covered patio that offers shade with appropriate furniture for residents to use. LPA observed a locked shed being used for storage. Side gate was checked to insure it was clear of obstruction.

Living room: LPA and administrator tried to enter through an emergency exit sliding glass door located by the living room. Staff #1 (S1) inside the facility had to assist us with entering the facility. The living room was clean and properly furnished. Fireplace is not in use and secured with a screen.

Kitchen/ Dinning area: The kitchen was observed to be clean and clear of clutter. Appliances and fixtures were functioning properly. LPA observed cleaning products kept locked under the kitchen sink. LPA observed knives and sharps locked in drawer. LPA observed a sufficient amount of 2- day perishable and 7-day non-perishable food at the facility; properly stored. LPA observed one (1) fire extinguishers fully charged with a last serviced date of 03/06/2023. Dining area had appropriate table and chairs to sit the capacity of the facility.

Medications: Centrally stored medications are maintained in a locked designated cabinet located in the kitchen. Medications were observed locked. LPA and Administrator reviewed and counted residents' medications. LPA observed pill organizers filled with pills for two (2) out two (2) residents in care. Administrator stated they will immediately discontinue the use of the pill organizer and keep pills in original medicine containers. Medication requiring refrigeration is located in a small fridge observed locked on the kitchen counter. Different pharmacies are being utilized for residents. Refills are either done automatically or ordered by the physician and family members are responsible for providing medications or refills to the facility. Medication Records were reviewed for proper documentation. Medication records are maintained manually.

At 10:36 a.m. LPA observed Administrator test a dual smoke and carbon monoxide detector. Detector is hardwired and interconnected to other detectors located through out the facility. Detectors were observed to be functioning properly. There is a fire door leading to the bedrooms that automatically closed during the test. (LIC809-C Continued on next page)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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: AMARE VILLA	FACILITY NUMBER: 197610254
	VISIT DATE: 05/15/2023

NARRATIVE

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(Continued LIC809-C)
At approximately 10:45 a.m. LPA conducted and/or attempted interviews with two (2) out of two (2) residents, the administrator, and S1 who was present at the facility.

Resident/Staff Records: At approximately 11:10 a.m. two (2) out two (2) resident records and (2) staff records were reviewed to insure compliance.

Deficiency cited on LIC809-D. Appeal Rights provided. Exit Interview conducted. 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: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 05/15/2023 02:47 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: AMARE VILLA	FACILITY NUMBER: 197610254
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in two (2) out of two (2)residents' medications by not storing medications in their originally received containers and storing them in a pill organizer which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/19/2023
	Plan of Correction
1 2 3 4	Administrator immediately returned medications to original containers and discontinued the use of the pill organizer. POC completed on todays visit.

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: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC809 (FAS) - (06/04)

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