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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
198602860
Report Date:
05/16/2024
Date Signed:
05/16/2024 05:46:05 PM
Document Has Been Signed on
05/16/2024 05:46 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:
LITTLE VILLA
FACILITY NUMBER:
198602860
ADMINISTRATOR:
HENG, SANG A
FACILITY TYPE:
740
ADDRESS:
3040 E. EDDES STREET
TELEPHONE:
(213) 910-0442
CITY:
WEST COVINA
STATE:
CA
ZIP CODE:
91791
CAPACITY:
6
CENSUS:
0
DATE:
05/16/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
04:25 PM
MET WITH:
Sang Heng
TIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with Administrator Sang Heng allowed the entry of the facility. The purpose for the visit was explained. The facility is licensed for
AGE RANGE 60 AND OVER. 6 NON-AMBULATORY, OF WHICH 1 IS BEDRIDDEN. HOSPICE WAIVER FOR 3
. Facility has fire clearance for 6 non-ambulatory residents, one of which is bedridden. Currently there's no resident reside in the facility.
LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control:
The facility does not have a infection control plan in file and administrator does not have a health screening report with chest x ray and the administrator certificate is not updated.
Operational Requirement:
The facility does not have any proof of liability insurance for the facility. The facility does not have at lease one person has CPR certificate.
Physical Plant and Environmental Safety:
The facility includes family room, dining area, kitchen, living room, three residents rooms and two bathrooms and storage room. Currently one bathroom is renovated and the bathroom is not in a operable condition. The bathrooms also have grab bars and non-skid mat. LPA was was not able to check the hot water temperature due to the water was shut off now due to the renovation.
Staffing:
Currently no staff is working at the facility.
Personnel Records-Training:
The administrator (Sang Heng) certificate is expired and currently no staff is working at the facility.
Resident Records/Incident Reports:
Currently facility has no residents reside and no file to be reviewed.
Residents Right Information:
LPA did not observe any poster for complaint's information or resident right in the facility
Planned Activities
: Currently there's no residents reside in the facility
Food Service:
Currently there's no resident reside in the facility.
(See LIC 809C for continuation)
SUPERVISOR'S NAME:
David Sicairos
TELEPHONE:
(323)980-4934
LICENSING EVALUATOR NAME:
Christine Wong
TELEPHONE:
(323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE:
04/18/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/18/2024
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
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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:
LITTLE VILLA
FACILITY NUMBER:
198602860
VISIT DATE:
05/16/2024
NARRATIVE
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Incident Medical and Dental:
Currently there's no resident reside in the facility and therefore there's no medication in the facility.
Disaster Preparedness
: Facility does not have an updated emergency and disaster plan posted in the facility
Residents with Special Health Needs:
Currently there's no resident reside in the facility.
Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8
Exit interview was conducted, Appeals Rights discussed and a copy of the report was given to the Administrator Sang Heng
(LPA reviewed the facility Licensing fee and it's not updated and it's due on 4/10/2024)
SUPERVISOR'S NAME:
David Sicairos
TELEPHONE:
(323)980-4934
LICENSING EVALUATOR NAME:
Christine Wong
TELEPHONE:
(323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE:
05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/16/2024
LIC809
(FAS) - (06/04)
Page:
8
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Document Has Been Signed on
05/16/2024 05:46 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
GREATER LA AC/SC
,
1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
LITTLE VILLA
FACILITY NUMBER:
198602860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/16/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, The administrator does not have any health screening with TB test result which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/30/2024
Plan of Correction
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The administrator will send the health screening form with TB test result 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:
David Sicairos
TELEPHONE:
(323)980-4934
LICENSING EVALUATOR NAME:
Christine Wong
TELEPHONE:
(323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE:
05/16/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/16/2024
LIC809
(FAS) - (06/04)
Page:
2
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Document Has Been Signed on
05/16/2024 05:46 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
GREATER LA AC/SC
,
1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
LITTLE VILLA
FACILITY NUMBER:
198602860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/16/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(b)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, the administrator certificate was never renewed since 2019 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/30/2024
Plan of Correction
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LPA will renew the administrator certificate and send the updated Administrator Certificate or renew adminsitrator form to LPA by POC due date.
Type B
Section Cited
CCR
87470(c)(1)(C)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (C) An Infection Control Training Plan.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the facility does not have any infection cotnrol plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/30/2024
Plan of Correction
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4
The administrator will send the copy of infection control plan 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:
David Sicairos
TELEPHONE:
(323)980-4934
LICENSING EVALUATOR NAME:
Christine Wong
TELEPHONE:
(323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE:
05/16/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/16/2024
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
05/16/2024 05:46 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
GREATER LA AC/SC
,
1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
LITTLE VILLA
FACILITY NUMBER:
198602860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/16/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the facility does not have any updated liabiltiy insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/30/2024
Plan of Correction
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The facility send the updated liability insurance to LPA by POC due date.
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on obsevation, due to the facility bathroom is currently rennovated and there's no water supplies in the facility and the toilet, handwashing is not in a operating condition hich poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/16/2024
Plan of Correction
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The administrator will send LPA a plan about the rennovation with start date and end date to LPA by POC due date and will update LPA with the progress.
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)980-4934
LICENSING EVALUATOR NAME:
Christine Wong
TELEPHONE:
(323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE:
05/16/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/16/2024
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
05/16/2024 05:46 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
GREATER LA AC/SC
,
1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
LITTLE VILLA
FACILITY NUMBER:
198602860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/16/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, LPA did not have at least one person who has CPR certficiate which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/30/2024
Plan of Correction
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The administrator will send the copy of CPR certfiicate to LPA by POC due date.
Type B
Section Cited
CCR
87415(a)
Night Supervision
(a) The following persons providing night supervision from 10:00 p.m. to 6:00 a.m. shall be familiar with the facility's planned emergency procedures, shall be trained in first aid as required in Section 87465, Incidental Medical and Dental Care Services, and shall be available as indicated below to assist in caring for residents in the event of an emergency:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, , LPA did not observe administrator has any facility planned emergency procedure training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/30/2024
Plan of Correction
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3
4
The administrator will send the training log about facility planned emergency procedure training 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:
David Sicairos
TELEPHONE:
(323)980-4934
LICENSING EVALUATOR NAME:
Christine Wong
TELEPHONE:
(323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE:
05/16/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/16/2024
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
05/16/2024 05:46 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
GREATER LA AC/SC
,
1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
LITTLE VILLA
FACILITY NUMBER:
198602860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/16/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA did not observe any personnel records in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/31/2024
Plan of Correction
1
2
3
4
The administrator will ensure the personnel record are maintained in the facility and will send a letter and indicate where the personnel record will be located to LPA by POC due date.
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPA did not administrator certificate was updated and administrator's name was not on CCL website which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
06/16/2024
Plan of Correction
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2
3
4
The administrator will reapply for the administrator certficiate and send the proof 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:
David Sicairos
TELEPHONE:
(323)980-4934
LICENSING EVALUATOR NAME:
Christine Wong
TELEPHONE:
(323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE:
05/16/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/16/2024
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
05/16/2024 05:46 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
GREATER LA AC/SC
,
1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK
,
CA
91754
FACILITY NAME:
LITTLE VILLA
FACILITY NUMBER:
198602860
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
05/16/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA did not observe any Complaint Poster or personal right post in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
05/30/2024
Plan of Correction
1
2
3
4
The adminsitrator will post the RCFE complaint poster and personal right poster in the facility and send the picture 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:
David Sicairos
TELEPHONE:
(323)980-4934
LICENSING EVALUATOR NAME:
Christine Wong
TELEPHONE:
(323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE:
05/16/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/16/2024
LIC809
(FAS) - (06/04)
Page:
7
of
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