Community Care Licensing

SUPERVISOR'S NAME: Lisa Hicks TELEPHONE: (323) 981-3972 LICENSING EVALUATOR NAME: Alberto Lopez TELEPHONE: 323-980-4926 LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023

Document Has Been Signed on 08/15/2023 03:58 PM - It Cannot Be Edited

FACILITY NAME: VILLA VICTORIA	FACILITY NUMBER: 198603439
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2023

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, the licensee did not comply with the section cited above. Facility has 3 bedridden residents and no fire clearance for that poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/17/2023
	Plan of Correction
1 2 3 4	Administrator will contact Fire department for fire clearance and send proof to LPA by POC date.

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Raid canister was accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2023
	Plan of Correction
1 2 3 4	Staff put RAID can away. ****No further action required***

SUPERVISOR'S NAME: Lisa Hicks TELEPHONE: (323) 981-3972 LICENSING EVALUATOR NAME: Alberto Lopez TELEPHONE: 323-980-4926 LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023

Document Has Been Signed on 08/15/2023 03:58 PM - It Cannot Be Edited

FACILITY NAME: VILLA VICTORIA	FACILITY NUMBER: 198603439
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2023

Request Denied

Type A

Section Cited

CCR

87458(a)

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. 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. Four residents did not have LIC602 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Administrator will obtain Updated LIC602 for all residents send proof to LPA by POC date.

Type A

Section Cited

CCR

87555(b)(26)

(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and 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
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. Facility does not have 7 days nonperishable food on hand which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Administrator will purchase 7 days nonperishable food send proof to LPA by POC date

SUPERVISOR'S NAME: Lisa Hicks TELEPHONE: (323) 981-3972 LICENSING EVALUATOR NAME: Alberto Lopez TELEPHONE: 323-980-4926 LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023

Document Has Been Signed on 08/15/2023 03:58 PM - It Cannot Be Edited

FACILITY NAME: VILLA VICTORIA	FACILITY NUMBER: 198603439
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2023

Request Denied

Type A

Section Cited

CCR

87555(b)(27)

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above roaches were observed in kitchen cabinets which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Administrator will call exterminator to address roaches and rat infestation and send proof to LPA by POC date.

Type A

Section Cited

CCR

87465(h)(2)

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Medications were accessible to residents and in their rooms which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Administrator will remove medications from residents room or purchase lock boxes if resident's MD allows self administration.

SUPERVISOR'S NAME: Lisa Hicks TELEPHONE: (323) 981-3972 LICENSING EVALUATOR NAME: Alberto Lopez TELEPHONE: 323-980-4926 LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023

Document Has Been Signed on 08/15/2023 03:58 PM - It Cannot Be Edited

FACILITY NAME: VILLA VICTORIA	FACILITY NUMBER: 198603439
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2023

Request Denied

Type A

Section Cited

CCR

87633(h)

(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: 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. Their is no record of residents which receive hospice which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Administrator will send notice of hospice services for residents at facility who are under hospice by POC date.

Request Denied

Type A

Section Cited

CCR

87705(f)(1)

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPAs observed knifes in kitchen accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2023
	Plan of Correction
1 2 3 4	Administrator will lock up sharps and all knifes and make them unaccessible to residents by POC and send proof to LPA by POC date.

SUPERVISOR'S NAME: Lisa Hicks TELEPHONE: (323) 981-3972 LICENSING EVALUATOR NAME: Alberto Lopez TELEPHONE: 323-980-4926 LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023

Document Has Been Signed on 08/15/2023 03:58 PM - It Cannot Be Edited

FACILITY NAME: VILLA VICTORIA	FACILITY NUMBER: 198603439
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2023

Type B

Section Cited

HSC

1569.618(b)(3)

(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: (3) Training to effectively interact with emergency personnel in the event of an emergency call, including an ability to provide a resident’s medical records to emergency responders. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview the licensee did not comply with the section cited above . Administrator is at facility only one hour or two per week and has no offical designated substitute. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2023
	Plan of Correction
1 2 3 4	Administrator will designate a substitute to take care of her responsibilities when not availible and send proof to LPA by POC date

SUPERVISOR'S NAME: Lisa Hicks TELEPHONE: (323) 981-3972 LICENSING EVALUATOR NAME: Alberto Lopez TELEPHONE: 323-980-4926 LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023

Document Has Been Signed on 08/15/2023 03:58 PM - It Cannot Be Edited

FACILITY NAME: VILLA VICTORIA	FACILITY NUMBER: 198603439
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2023

Type B

Section Cited

CCR

87208(a)

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. 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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Facility had not plan of operation on file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/22/2023
	Plan of Correction
1 2 3 4	Administrator will send plan of operation to LPA by POC date.

Type B

Section Cited

HSC

1569.605

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
1 2 3 4	Based on record review, the licensee did not comply with the section cited above. Facility did not have proof of liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Administrator will send proof of liability insurance by POC date to LPA.

SUPERVISOR'S NAME: Lisa Hicks TELEPHONE: (323) 981-3972 LICENSING EVALUATOR NAME: Alberto Lopez TELEPHONE: 323-980-4926 LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023

Document Has Been Signed on 08/15/2023 03:58 PM - It Cannot Be Edited

FACILITY NAME: VILLA VICTORIA	FACILITY NUMBER: 198603439
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2023

Request Denied

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview the licensee did not comply with the section cited above. The clothes dryer and AC is not working which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/25/2023
	Plan of Correction
1 2 3 4	Administrator will repair or replace clothes dryer and AC unit by POC date and send proof to LPA.

Request Denied

Type B

Section Cited

CCR

87303(a)(1)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, the licensee did not comply with the section cited above. Ramp in hall wall is in need of repair or replacement which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/25/2023
	Plan of Correction
1 2 3 4	Administrator will repair ramp and send proof to LPA by POC.

SUPERVISOR'S NAME: Lisa Hicks TELEPHONE: (323) 981-3972 LICENSING EVALUATOR NAME: Alberto Lopez TELEPHONE: 323-980-4926 LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023

Document Has Been Signed on 08/15/2023 03:58 PM - It Cannot Be Edited

FACILITY NAME: VILLA VICTORIA	FACILITY NUMBER: 198603439
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/15/2023

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, record review, the licensee did not comply with the section cited above. Facility has not had an emergency drill which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/16/2023
	Plan of Correction
1 2 3 4	Administrator will conduct emergecny drill and send proof to LPA by POC date.

Type B

Section Cited

CCR

87705(c)(5)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above. No residents with dementia had annual assessments which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/25/2023
	Plan of Correction
1 2 3 4	The administrator will get updated medical assessment on all residents with dementia and send proof to LPA by POC date.

SUPERVISOR'S NAME: Lisa Hicks TELEPHONE: (323) 981-3972 LICENSING EVALUATOR NAME: Alberto Lopez TELEPHONE: 323-980-4926 LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023

FACILITY NAME: VILLA VICTORIA	FACILITY NUMBER: 198603439
	VISIT DATE: 08/15/2023