198203965-6-14-2024-11-AS-EDAT-D68U2U-20240614151230

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198203965
Report Date: 06/14/2024
Date Signed: 06/14/2024 03:12:42 PM

Document Has Been Signed on 06/14/2024 03:12 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	VILLA CHRISTA		FACILITY NUMBER:	198203965
ADMINISTRATOR:	ARLENE FELICIANO		FACILITY TYPE:	740
ADDRESS:	16421 CHANERA AVE		TELEPHONE:	(310) 719-8997
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90504
CAPACITY:	6	CENSUS: 5	DATE:	06/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:26 AM
MET WITH:	Arelene Feliciano		TIME COMPLETED:	12:07 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 06/14/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with administrator Arlene Feliciano and explained the purpose of today’s visit. The facility is licensed to operate for six (6) non-ambulatory of which one (1) may be on hospice ages 60 and above. The facility is approved for (1) hospice resident. Currently, the facility has zero (0) residents in hospice care. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident's rooms, two (2) common bathrooms, one (1) staff room, a living area, a dining area, a kitchen, and an outside patio area. LPA and caregiver toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 105.6 degree F. A comfortable temperature of 73 degree F was maintained in the facility. LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguisher were charged, smoke detectors and carbon monoxide were operable. A review of the Medication Administration Record (MAR) was complete and accurate. The facility has conducted a disaster drill on 06/12/24. A landline telephone was in working condition. A review of staff CPR/First Aid training is current. Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VILLA CHRISTA	FACILITY NUMBER: 198203965
	VISIT DATE: 06/14/2024

NARRATIVE

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. The facility has current liability insurance on file effective 10/29/23 - 10/29/24. The facility is current on Community Care Licensing annual dues.

An audit of residents #1-#5 (R1-R5) service files and staff #1-#4 (S1-S4) personnel files revealed to be complete.

Deficiencies:
During resident's audit of service files, (R1) diagnosed with dementia does not have a current medical and appraisal assessment. The last medical assessment and appraisal was in 2019.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Arlene Feliciano and a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/14/2024 03:12 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: VILLA CHRISTA	FACILITY NUMBER: 198203965
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia(c) Licensees...shall be responsible for ensuring the following:(5)...an annual medical assessment...a reappraisal done at least annually...shall include...resident’s dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record reviews the licensee failed to ensure that residents who are diagnosed with dementia (R1) obtained an annual medical assessment and appraisal. Which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/28/2024
	Plan of Correction
1 2 3 4	The administrator agreed to obtain a medical assessment for R1 and will create a plan to ensure that each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment. Proof of correction will be submitted to CCL via email at ernand.dabuet@dss.ca.gov. The administrator may ask for an extension if more time is needed via email.

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: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC809 (FAS) - (06/04)

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