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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000886
Report Date: 12/21/2023
Date Signed: 12/21/2023 11:45:06 AM

Document Has Been Signed on 12/21/2023 11:45 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
ORANGE COUNTY RO, 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:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jennifer CriddleTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Ruth Martinez is conducting this unannounced visit for the purpose of completing an annual required inspection. LPA arrived at the facility was greeted and granted entry by Jennifer Criddle, Administrator and LPA explained the nature of the visit.

One client resides at this facility, LPA was informed client was out in the community. LPA accompanied with Administrator began the tour of the inside and outside of the facility. LPA observed required department postings posted on the wall of facility. Facility stays within the capacity limitations. There is a minimum of one week of non-perishables foods and two days of perishables foods available. The facility is maintained at a comfortable temperature. LPA inspected that medication are centrally stored in a safe locked storage cabinet located in laundry unit. LPA reviewed medication and observed medication was labeled and stored inaccessible to clients in care. LPA inspected the bathroom and LPA measured the hot water temperature which measured 118.2 Fahrenheit degrees. All bathrooms observed to have a supply of soap, toilet paper and towels. The facility is equipped with sufficient hand hygiene, cleaning, and disinfecting supplies. LPA observed that toxic chemicals, cleaning solutions and disinfectants are stored locked in a cabinet located in laundry unit. The facility has an available clean supply of linens. LPA inspected client’s bedrooms which has sufficient lighting to ensure the safety and comfort. All bedrooms observed to have all required components. Storage space is provided for clients in their bedroom. Smoke detectors were tested and found to be operational. LPA toured the outside of the facility and observed outdoor passageways are free of obstructions. LPA observed there is seating areas for client’s enjoyment. LPA observed a fire extinguisher charged and mounted in the entrance of the hallway and fire drill are conducted monthly. LPA began review of records. LPA reviewed one client records. All the required documentation was present and current in client’s files reviewed. Client handles their own P&I funds, LPA reviewed IPP and verified client can handle monies independently. LPA reviewed two employee records. All employees present have a criminal record

Continued on LIC809-C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
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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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 GARDENS
FACILITY NUMBER: 306000886
VISIT DATE: 12/21/2023
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clearance and are associated to the facility. LPA observed records reviewed have a current First Aid certificate.

Based on the observation made during today’s visit, no deficiencies were noted today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with the facility representative, and a copy of this report was provided to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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