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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204587
Report Date: 02/15/2023
Date Signed: 02/15/2023 02:32:12 PM


Document Has Been Signed on 02/15/2023 02:32 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:
02/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:David Kim, Administrator TIME COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. The purpose of the visit was explained to Administrator David Kim.
There are 10 residents ages 60 and above [ 6 ambulatory, 3 non-ambulatory, & 1 bedridden]. A Dementia waiver and an approved hospice waiver for 6 residents is in place. The last fire emergency drill was conducted on 2/6/2023. The last fire Inspection was completed on 8/29/2022 by Eminent Fire Protection. Administrator certificate expires 3/9/2024.

OBSERVATIONS

Infection Control:

  • COVID-19 Infection Control Practices and signs were observed in the main entrance and restrooms. A visitor sign in station was observed outside the main entrance. Per Administrator, visitors are no longer being screened due to public health order changes in 2022. Visitors are screened by staff only if needed.
  • Staff wear masks. Residents do not wear masks due to health and cognitive issues.
  • Sufficient supply of Personal Protective Equipment (PPE's) was observed. The facility has a contingency plan for back-up staffing if needed.
  • The facility submitted a COVID-19 Mitigation Plan. An Infection Control Plan (ICP) has not been submitted. Submit the ICP as soon as possible. The plan should be reviewed and updated as necessary. Administrator has agreed to submit their Infection Control Plan by [up to 60 days from inspection].


Medications:
  • 30-day centrally stored resident medications were observed.

*See LIC 809C for report continuation.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VILLA, THE
FACILITY NUMBER: 198204587
VISIT DATE: 02/15/2023
NARRATIVE
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Physical Plant:
  • The facility is a single story building consisting of 11 resident bedrooms, 7 bathrooms, living room, dining room, tv room kitchen, indoor patio, laundry room, two (2) shaded patio areas, and detached garage.

  • The majority of resident beds did not have mattress pads. Administrator put mattress pads on all beds during the visit.

  • The auditory alarm in the main entrance door was turned off. Administrator immediately turned it on.

  • Eleven (11) resident rooms were inspected. Rooms 1 & 2 are presently being used as living quarters by Licensee. Administrator was advised to update and submit to Community Care Licensing the updated Plan of Operation/Program Design and facility sketch to reflect the changes in facility operation.

Food Service:
  • Sufficient food supply is stored in the kitchen and outdoor food storage areas consisting of: 2-day perishables, 7-day non-perishables, and emergency food supplies.

Resident Files:
  • Three (3) residents are in enrolled in hospice and one (1) resident is bedridden.


Staff Files:
  • Criminal Background Clearance was checked.

Liability Insurance:
  • Proof of liability insurance was provided. It expires 12/31/2023.

A technical advisory was issued pertaining to Infection Control Plan.
Deficiencies were cited
Exit interview was conducted with Administrator David Kim. A copy of the report and appeal rights was issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/15/2023 02:32 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: 02/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that, the main entrance door auditory alarm was turned off because the wooden door is kept opened by staff; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2023
Plan of Correction
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Administrator shall ensure that all auditory devices on the exit doors and windows are turned on, and operable at all time. Administrator immediately turned on the auditory alarm. CLEARED during the visit.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 02/15/2023 02:32 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: 02/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services
Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths....
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on physical plant observations, the majority of resident beds did not have mattress pads on the hospital beds and/or regular beds; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2023
Plan of Correction
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Administrator agreed to ensure that all resident beds have mattress pads at all times. Administrator placed mattress pads on all resident beds during the visit. CLEARED.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 02/15/2023 02:32 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: 02/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation.... Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that rooms 1 &2 are being used by live-in staff and licensee to care for family member, and not as resident bedrooms; which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/15/2023
Plan of Correction
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Licensee agreed to submit a written plan of correction, updated Plan of Operation, and facility sketch regarding the facility room changes/licensee living quarters.
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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5