198204587-2-18-2025-28-AS-THEA-DDZUU2-20250218145250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204587
Report Date: 02/18/2025
Date Signed: 02/18/2025 02:52:57 PM

Document Has Been Signed on 02/18/2025 02:52 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	VILLA, THE		FACILITY NUMBER:	198204587
ADMINISTRATOR/ DIRECTOR:	DAVID KIM		FACILITY TYPE:	740
ADDRESS:	12565 DOWNEY AVENUE		TELEPHONE:	(562) 861-6694
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90242
CAPACITY: 15	TOTAL ENROLLED CHILDREN: 0	CENSUS: 13	DATE:	02/18/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:39 PM
MET WITH:	David Kim - Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:05 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	Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Administrator David Kim and explained the purpose for today’s visit. The facility is licensed to serve 1 Ambulatory Resident and 12 Non-Ambulatory Residents ages 60 and over (of which 6 may be bedridden). Facility has a hospice waiver for 6, there are currently 4 residents using hospice services. The Facility is a single story building located in Downey, CA. A tour of the facility included: 11 resident bedrooms, 7 bathrooms, living room, dining room, tv room, kitchen, laundry room, two (2) shaded patio areas, detached garage and tool sheds used for storage and emergency food supply. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: Facility maintains the required Infection Control Plan. Operational Requirements: The facility has an approved fire clearance and maintain the required liability insurance. Physical Plant & Environment Safety: LPA toured facility, residents’ bedrooms/units were checked and had the required closet/drawer space to accommodate each resident comfortably available. The resident rooms have signal systems that were tested an operating properly. There are smoke detectors, carbon monoxide detectors and an emergency sprinkler system throughout the facility that are operable and in compliance. The fire extinguishers were observed throughout the facility and are fully charged. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available. The hot water temperature was tested throughout the facility and measured within the required range of 105-120 degrees. There is a shaded patio/garden areas for residents. Staffing: There appears to be sufficient staffing at all times in the facility. With night staff that is trained and able to assist in care and supervision of the residents in the case of an emergency.(Continued on LIC809-C)

David Sicairos	TELEPHONE: (323) 981-3982
Tena Herrera	TELEPHONE: 323-980-4633
	DATE: 02/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA, THE	FACILITY NUMBER: 198204587
	VISIT DATE: 02/18/2025

NARRATIVE

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Personnel Records-Training: Staff have criminal record clearance, current First-Aid training along with training in postural supports, Alzheimer’s and Dementia, medication assistance, and other ongoing training are documented in personnel files. LPA reviewed 5 staff files with no issues observed, 2 staff were missing their first-aid training (prior to end of visit both staff were able to show completion of training done on 2/18/25) citation issued as both staff had expired first-aid certificates from 9/2024 and 12/2024 (details found on LIC800-D). Administrator David Kim certificate expires on 6/21/2025.
Resident Records-Incident Reports: Resident files are kept in a secure location and have the following documents in their files - Pre-admission appraisal/Appraisal Needs & Services Plan, Admission Agreements, Identification & Emergency Information and current Physician's Report. LPA reviewed 5 Resident Files with no issues observed.
Residents Rights-Information: Residents are provided with telephone and internet at the facility. The facility has the following posters posted on each floor/section: Residents Rights, Complaint Poster, and Ombudsman.
Planned Activities: Facility provides scheduled activities with a monthly calendar. There is sufficient space both indoor and outdoor for activities.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Incidental Medical & Dental: Medication is properly labeled and are centrally stored and are in their original containers.
Disaster Preparedness: The facility has an Emergency Disaster Plan with contact numbers and at least 2 relocation sites.
Residents with Special Health Needs: Facility admits residents with dementia and staff files reviewed today all have required training documented.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiency observed during the visit will be cited on the 809D.

Exit interview held, a copy of the report and appeal rights were provided to Administrator David Kim.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/18/2025 02:52 PM - It Cannot Be Edited

Created By: Tena Herrera On 02/18/2025 at 02:37 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA, THE	FACILITY NUMBER: 198204587
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as 2 staff had expired first-aid certificates from 9/2024 and 11/2024, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/25/2025
	Plan of Correction
1 2 3 4	Both staff completed their online first-aid/cpr renewals and showed proof of completion to LPA prior to end of visit. POC was cleared during 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:

David Sicairos

TELEPHONE: (323) 981-3982

LICENSING EVALUATOR NAME:

Tena Herrera

TELEPHONE: 323-980-4633

LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025

LIC809 (FAS) - (06/04)

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