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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204587
Report Date: 02/25/2022
Date Signed: 02/25/2022 02:41:26 PM


Document Has Been Signed on 02/25/2022 02:41 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:VILLA, THEFACILITY NUMBER:
198204587
ADMINISTRATOR:DAVID KIMFACILITY TYPE:
740
ADDRESS:12565 DOWNEY AVENUETELEPHONE:
(562) 861-6694
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY:15CENSUS: 10DATE:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator David Kim TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Jose Villalobos made an unannounced Annual inspection focused on Infection Control. On today’s visit LPA met with Administrator David Kim and the purpose of the visit was discussed.

As a part of the inspection, LPA used the inspection tool, reviewed (6) client records, (2) staff files, and (6) client medications. Currently the facility has (10) clients. LPA also toured the facility. Facility is a one story residence with eleven (11) bedrooms. There are (7) bathrooms, a living room, family room, kitchen, central air and heating, dining area, laundry room, (2) shaded outdoor patios. Front and back yard is in good condition at time of visit. Washer/Dryer appliances observed. Toxins and sharps locked and inaccessible to clients. Resident bedrooms are equipped with required accomodations. Bathrooms have a working toilet, wash basin, and showers. Beds have the required linen/supplies which include, pillowcase, mattress padding, fitted sheet, blanket and bedspreads. Supply of hygiene supplies stored in for each resident. Fire alarms are interconnected and operational. Facility has a sprinkler system. Required postings observed. Water temperature within required tittle 22 regulations.

Infection control domain completed. Deficiency cited on 809-D page. An exit interview was conducted. Copy of this report provided to Administrator David Kim. Appeal rights provided
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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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Document Has Been Signed on 02/25/2022 02:41 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 CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: VILLA, THE
FACILITY NUMBER: 198204587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)


This requirement is not met as evidenced by:
LPA reviewed S1's file and observed S1's first aid certification expired 6/11/21.
Deficient Practice Statement
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Based on record review. the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/11/2022
Plan of Correction
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Administrator (S1) to aquire first aid certification and provide proof to licensing by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
LIC809 (FAS) - (06/04)
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