198204540-7-8-2022-11-AS-AALR-CG62MQ-20220708173132

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204540
Report Date: 07/08/2022
Date Signed: 07/08/2022 05:31:47 PM

Document Has Been Signed on 07/08/2022 05:31 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	VILLA MIRAGE INC.		FACILITY NUMBER:	198204540
ADMINISTRATOR:	YOLANDA LEE		FACILITY TYPE:	740
ADDRESS:	2655 BARRY AVENUE		TELEPHONE:	(310) 479-2984
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90064
CAPACITY:	6	CENSUS: 3	DATE:	07/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Yolanda Lee		TIME COMPLETED:	05:00 PM

NARRATIVE

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On 7/8/2022, Licensing Program Analyst (LPA) Antonia Alvizar conducted an unannounced annual required visit with a primary focus on Infection Control measures. LPA was met by Yolanda Lee, Administrator and the purpose of today’s visit was explained. The facility is licensed to serve 6 Residential - Elderly and (ages 65 and older).

All currently residents are private in placement. There is (1) ambulatory and (2) non-ambulatory residents. The facility is a single story structure located in a residential neighborhood. It consists of the following: 3 bedrooms, 2 bathrooms, living room, kitchen, dining room, office area, service area, shaded area, indoor and outdoor activity area, laundry room.

LPA and Administrator toured the physical plant. There were no bodies of water or obstructions on the premises. Beds and bedding supplies were in good condition, adequate lighting provided, storage for residents 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.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. The kitchen was inspected and there is a 7-day supply of perishable and a 7-day supply of non-perishable food available, maintained properly. Water temperature in restroom #1 was 111.4 Fahrenheit.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA MIRAGE INC.	FACILITY NUMBER: 198204540
	VISIT DATE: 07/08/2022

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On 7/8/2022 at 8:55 A.M. LPA observed (2) fire extinguishers are located in the kitchen and service room with no service tag there was a purchased receipt dated (3/22/2014) displayed on the extinguishers. The licensee has confirm that extinguisher have not being serviced. During today’s visit licensee purchased new fire extinguishers.

On 7/8/2022 at 9:05 A.M. LPA observed OTC medications were on kitchen counter and accessible to residents. Licensee confirmed that medication belonged to residents. During today's visit licensee locked the OTC medications.

On 7/8/2022 at 12:15 AM LPA observed that the detached garage was converted to an Accessible Dualing Unit (ADU). The permit paperwork review by LPA shows ADU address as 2657 S. Barry Ave Los Angeles, CA 90064.

During the visit, LPA observed the facility infection control practices. LPA observed screening protocol for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, a 30-day supply of Personal Protective Equipment (PPE) is available and sign in and out logs for visitors and staff are present in the facility.

An exit interview was conducted, and a copy of this report was provided to Yolanda Lee, Administrator

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/08/2022 05:31 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA MIRAGE INC.	FACILITY NUMBER: 198204540
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(2)

8746 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation during plant inspection, licensee failed to ensure OTC medications were kept locked and inaccessible at all times to residents. This violation posess a potential health, safety risk to residents in care.
	POC Due Date: 07/15/2022
	Plan of Correction
1 2 3 4	Licensee will adhere to the regulations and will ensure that OTC medications are kept locked and inaccessible at all time. Lisensee will ensure to provide plan of correction sent by fax at 323-981-1781 to El Segundo Regional offiice by 7/15/2022. This citation was corrected during visit on 7/8/2022 Licensee locked the OTC medications during today's visit.

Type B

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
	Deficient Practice Statement
1 2 3 4	Based on LPA observation during plant inspection, Licensee failed to ensure fire extinguisher is serviced on an annual bases. This violation possess a potential Health and Safety risk to residents in care.
	POC Due Date: 07/15/2022
	Plan of Correction
1 2 3 4	Licensee will adhere to the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Lisensee will ensure to provide plan of correction sent by fax at 323-981-1781 to El Segundo Regional office by 7/15/2022.* During today's visit licensee purchased a new fire extinguisher.

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia Alvizar	TELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

LIC809 (FAS) - (06/04)

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