300605363-5-9-2024-22-AS-JCHO-D554A9-20240509185534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 300605363
Report Date: 05/09/2024
Date Signed: 05/09/2024 06:55:39 PM

Document Has Been Signed on 05/09/2024 06:55 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	VILLA REGINA III		FACILITY NUMBER:	300605363
ADMINISTRATOR:	MARK FISK		FACILITY TYPE:	740
ADDRESS:	24832 ARGUS		TELEPHONE:	(949) 295-9191
CITY:	MISSION VIEJO	STATE: CA	ZIP CODE:	92691
CAPACITY:	6	CENSUS: 6	DATE:	05/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Donald Fisk- Administrator Brigitte Fisk- Administrator		TIME COMPLETED:	07:15 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 Analysts (LPAs) Jessica Cho and Rose Ruppert conducted an unannounced Required 1-Year annual visit using the CARE Inspection Tool. Upon arrival at the facility, LPAs met with Caregiver Aurea Mihardjo and explained the purpose of the visit. The facility is licensed to operate for six non-ambulatory and maintains a hospice waiver for four. The facility is a single-story structure located in a residential neighborhood which consists of the following: five resident bedrooms, one staff bedroom, two bathrooms, living room, family room, dining area, kitchen, laundry room, outdoor patio area, and a two car garage which is being utilized as a storage and did not have a clear passageway to walk inside. LPAs observed clutter which includes but is not limited to: refrigerator, wooden panels, dresser, extra mattresses, boat, and additional items. LPAs toured the interior and exterior of the facility with Administrator Mark Fisk who arrived at 12:45pm. Administrator Brigitte Fisk also arrived shortly. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for each client’s personal belongings were observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. All bedrooms were inspected. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 118.4 degrees Fahrenheit in both bathrooms. A comfortable indoor temperature of 72 degrees Fahrenheit was maintained in the facility. LPAs observed the facility to be sanitary and appropriately furnished at the time of visit. Sharps and toxins were stored and inaccessible to the residents. Three cleaning solutions were unsecured in the resident's closet, however due to all the residents being non-ambulatory, licensee was reminded of the regulations and the items were secured during the visit. The kitchen was inspected and there is a two-day supply of perishable and seven-day supply of non-perishable food available and maintained properly. The facility has one fire extinguisher that was charged and serviced on October 4, 2023 and another in the garage. Smoke/carbon monoxide detectors were tested and operational.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: VILLA REGINA III	FACILITY NUMBER: 300605363
	VISIT DATE: 05/09/2024

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
26
27
28
29
30
31
32

The facility did not conduct emergency drills and did not maintain a record. A working telephone (949-998-9191) remains available. The First Aid Kit contained all the necessary elements. During the visit, LPAs observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPAs observed the facility has a 30-day supply of Personal Protective Equipment (PPE). The 'See Something Say Something" (PUB475) was maintained in the correct size that exceeded 20"x26."

LPAs conducted an audit of six residents' files and two personnel files. LPAs conducted two staff and three resident interviews. Interviews with three remaining residents were not conducted due to residents sleeping. Medications were audited for two out of the six residents. Discrepancies were noted for one out of the six residents.

The following were advised: clear the clutter in the garage, to ensure CCL is informed about the alterations made to the facility, audit medications to ensure the medications provided are current on the medication list, obtain a current Physician's Report for four out of the six residents, obtain a doctor's order for half bed rails for two residents, conduct emergency drills of various scenarios quarterly and maintain a record, and ensure the cleaning solutions are inaccessible at all times..

Deficiencies are being cited as per the Title 22, Division 6, Chapter 8 of the California Code of Regulations. Advisory Notes are also being issued, and an immediate civil penalty is being assessed. See LIC421IM. The remaining deficiencies and Advisory Note(s) will be addressed on the continuation annual inspection at a later date due to time constraints.

An exit interview was conducted with Administrators Brigitte Fisk, Mark Fisk, and Erin Fisk, however the reports were not signed by the administrator, and a copy of this report including the LIC9099-C, LIC9099-D, and the LIC421IM, and the appeal rights were provided at the end of the visit.

SUPERVISOR'S NAME: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 05/09/2024 06:55 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: VILLA REGINA III	FACILITY NUMBER: 300605363
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs' observations, interviews, and record review, bedroom #4 for the caretaker was occupied by a resident, two fire doors were removed, clutter was observed in the garage which prevented a clear entryway which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2024
	Plan of Correction
1 2 3 4	Licensee stated that they will submit a LIC200, provide an updated floor plan, submit a $25.00 check payable to the Department of Social Services, and to clear the clutter in the garage.

Type A

Section Cited

CCR

87608(a)(3)

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, interviews, and record review, facility did not have a doctor's order for the half rail for one out of the six residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/10/2024
	Plan of Correction
1 2 3 4	Bed rail was removed and corrected during the visit.

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: Lourdes Montoya	TELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3