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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601940
Report Date: 08/17/2023
Date Signed: 08/21/2023 11:27:13 AM

Document Has Been Signed on 08/21/2023 11:27 AM - 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: 25DATE:
08/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Joel Alonzo TIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angelica Rea visited facility to conduct the annual inspection. LPA met with Administrator Joel Alonzo, who assisted with the visit.

There are 4 Units which are the client living quarters. Each unit has 2 stories. On the first floor of each unit, there is a living and dining area, kitchen, a bathroom which is shared by the clients and 2 bedrooms. The clients do not cook in the kitchens. Each bedroom has 2 beds. Upstairs, in each unit, there are 2 bedrooms, a bathroom which is shared by the clients, and a storage closet.

There is sufficient closet & drawer space in the client bedrooms; Smoke detectors were tested and are functioning properly; carbon monoxide detectors were tested and functioning properly; poisons, cleaning solutions, disinfectants are inaccessible to clients; toilets, hand washing and bathing facilities were inspected; LPA observed a sufficient supply of extra linen; personal hygiene items such as soap, toilet paper, toothbrush, toothpaste, and combs are available; sharp knives are locked in the kitchen of unit 4, & inaccessible to clients. Freezers and refrigerators are clean and required temperature is maintained; all clients’ medication were labeled and maintained as required and stored inaccessible to the clients. Hot water temperature was recorded to be 119.3 degrees F.

LPA reviewed 4 client files and 3 staff files. LPA observed needs and services plans, admission agreements, physicians reports with TB test results, as well as other required documents. LPA also reviewed medication on today's visit.

Deficiencies cited on 809-D.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Angelica Rea
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 08/21/2023 11:27 AM - It Cannot Be Edited


Created By: Angelica Rea On 08/17/2023 at 05:03 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: 08/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) In all facilities with a licensed capacity of 16 or more clients, and all facilities having separate floors or separate buildings without full-time staff there shall be a signal system which has the ability to meet the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation, the licensee did not comply with the section cited above in 4 out of 4 units, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2023
Plan of Correction
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Licensee shall ensure that the facility has a signal system in each unit as required, and will send proof of correction to LPA by POC due date.
Type A
Section Cited
CCR
80076(a)(1)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

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 review of food supply which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee shall ensure that food(s) are checked for expiration dates, and discarded when they are not of good quality.
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 Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 08/21/2023 11:27 AM - It Cannot Be Edited


Created By: Angelica Rea On 08/17/2023 at 05:03 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: 08/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in review of food supply which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/18/2023
Plan of Correction
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Licensee shall ensure that the facility has a minimum of one week of perishable food and a minimum of two days of nonperishable foods as required, and will send proof of correction by POC date.
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 Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/21/2023 11:27 AM - It Cannot Be Edited


Created By: Angelica Rea On 08/17/2023 at 05:03 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: 08/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 2 bedrooms observed which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2023
Plan of Correction
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Licensee shall ensure that the closet door in Room 401, and dining room door are repaired by POC due date. Licensee to send proof of correction by POC due date.
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

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 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/18/2023
Plan of Correction
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Licensee shall ensure that the facility is kept clean and free of insects as required. Licensee will send proof of correction to LPA by POC due date.
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 Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 08/21/2023 11:27 AM - It Cannot Be Edited


Created By: Angelica Rea On 08/17/2023 at 05:03 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: 08/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

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 2 out of 2 bedrooms observed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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Licensee will ensure that all resident bedrooms have clean linen, including mattress pads. Licensee will send proof of correction by POC due date.
Type B
Section Cited
CCR
85088(c)(4)(B)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths. (B) The use of common towels and washcloths shall be prohibited.

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 8 out of 8 bathrooms observed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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Licensee will ensure that each bathroom has paper towels for residents to use. Licensee will send proof of correction to LPA by POC due date.
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 Hicks
LICENSING EVALUATOR NAME:Angelica Rea
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023


LIC809 (FAS) - (06/04)
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