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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000886
Report Date: 03/03/2022
Date Signed: 03/03/2022 02:40:17 PM

Document Has Been Signed on 03/03/2022 02:40 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VILLA GARDENSFACILITY NUMBER:
306000886
ADMINISTRATOR:ROSLYN A. GRAYFACILITY TYPE:
735
ADDRESS:17846 HELENA CIRCLETELEPHONE:
(714) 289-8820
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY: 4CENSUS: 1DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Rosyln Gray, AdministratorTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs), Kathrina Chin and Jessica Cho conducted an unannounced visit for the purpose of conducting a required annual visit. LPAs were greeted by Rosylnn Gray, Administrator and explained the purpose of the visit.

LPAs toured the facility. There is one resident residing in the facility and no active COVID-19 cases. All residents appeared clean and well taken care of. LPA observed required postings in the facility as well as hand washing signs in the restrooms. All bathrooms observed had ample soap/sanitizer and appeared clean. Resident bedrooms appeared clean and sanitary and had all required components. LPA observed the emergency disaster and evacuation plans. Facility has back-up emergency food and water supply as well as PPE supplies. Ms. Gray could not locate the copy of the Mitigation Plan.

Smoke detectors, carbon monoxide and auditory exit alarms were tested and were operational. Bathrooms were observed to be in good repair; and provided with grab bars and non-skid floor mats. Hot water was measured at 122.3 degrees Fahrenheit. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion, facility had patio furniture in good repair and a covered patio, and grounds were free of tripping hazards. The koi pod does not have a cover on half of the koi pod. Several cleaning solutions were unlocked and accessible to the resident.


The following deficiency is cited today as per Title 22 of the California Code of Regulations:

An exit interview was conducted, appeal rights explained and copy provided and a copy of this report was provided.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kathrina Chin
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2022
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 03/03/2022 02:40 PM - It Cannot Be Edited


Created By: Kathrina Chin On 03/03/2022 at 01:55 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: VILLA GARDENS
FACILITY NUMBER: 306000886

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(e)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the licensee did not comply with the section cited above as the koi pod was observed to be half uncovered as the half the cover was removed. This poses an immediate risk to the health and safety of residents in care.
POC Due Date: 03/04/2022
Plan of Correction
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Please have the koi pond cover fixed or replace by the due date.
Type A
Section Cited
CCR
80087(e)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with this regulation as LPAs observed Lysol spray, Disinfectant wipes, kitchen wax and laundry detergent and a cleaning supply container was left in the middle of the family room. This poses an immediate risk to the health and safety of residents in care.
POC Due Date: 03/03/2022
Plan of Correction
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Licensee to store and lock all cleaning supplies and solutions and to ensure that they are inaccessible to residents.
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:Sheila Santos
LICENSING EVALUATOR NAME:Kathrina Chin
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022


LIC809 (FAS) - (06/04)
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