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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601940
Report Date: 07/20/2022
Date Signed: 07/20/2022 04:22:01 PM

Document Has Been Signed on 07/20/2022 04:22 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 FLORAFACILITY NUMBER:
198601940
ADMINISTRATOR:ROSALINDA BUENVIAJEFACILITY TYPE:
735
ADDRESS:10932 CARMENITA RD.TELEPHONE:
(562) 941-5249
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 34CENSUS: 30DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Staff Joel AlonzoTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA)Jose Villalobos conducted an unannounced Required- 1 year visit focusing on COVID-19 Infection Control Practices. LPA met with staff Joel Alonzo and explained the purpose of the visit.

As a part of the inspection, LPA used the inspection tool, reviewed (7) client records, (3) staff files, and (7) client medications. Currently the facility has (30) clients. Facility is a multi home residence composed of 3 separated 2 story townhouses. Each section has (2) bathrooms, (5) client bedrooms for up to (2) clients each, a living room, a kitchen, dining area, laundry room. Attached car garage inaccessible to clients on each one as well. Yard area is in good condition at time of visit. Toxins and sharps locked and inaccessible to clients. Fire alarms are interconnected and operational. Sufficient supply of perishable for 2 days & non-perishable foods for 7 days were observed. Required postings observed. Water temperature within required tittle 22 regulations. Infection control domain completed.

The following was inspected and observed during the inspection
  • Seven (7) centrally stored resident medication records were reviewed. Medication errors were observed. Client #1 (C1) had bedtime medication Benzotropine and Risperidone for the date of 7/19/22 still in the bubble pack, yet was marked as given on Medication Administration Report )MAR). Client #2 (C2) Bedtime medication holds 4 medications per bubble. The bubble for 7/19/22 was popped but still had 1 of 4 medications inside the bubble. MARs record shows that all bedtime medications were taken by client on this day.

Deficiencies were cited. See LIC809D.
Exit interview was conducted with Joel Alonzo. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Jose Villalobos
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2022
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 07/20/2022 04:22 PM - It Cannot Be Edited


Created By: Jose Villalobos On 07/20/2022 at 02:41 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 FLORA
FACILITY NUMBER: 198601940

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)


This requirement is not met as evidenced by:

Client #1 (C1) had evening medication Benzotropine and Risperidone for the date of 7/19/22 still in the bubble pack, yet was marked as given on Medication Administration Report )MAR). Client #2 (C2) Bedtime medication holds 4 medications per bubble. The bubble for 7/19/22 was popped but still had 1 of 4 medications inside the bubble. MARs record shows that all bedtime medications were taken by client on this day.
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in (2) out of (7) medication file reviewed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Staff will schedule an in-service training on Medication Management for all facility staff in charge of medication administration and date provided to Licensing by POC due date. A copy of the materials discussed during the training and signatures of all staff present must be forwarded to the CCL office upon completion.
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 Fierros
LICENSING EVALUATOR NAME:Jose Villalobos
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022


LIC809 (FAS) - (06/04)
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