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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000886
Report Date: 12/05/2024
Date Signed: 12/05/2024 11:32:59 AM

Document Has Been Signed on 12/05/2024 11:32 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/
DIRECTOR:		ROSLYN A. GRAYFACILITY TYPE:
735
ADDRESS:17846 HELENA CIRCLETELEPHONE:
(714) 289-8820
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY: 4CENSUS: DATE:
12/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:08 AM
MET WITH:Roslyn GrayTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Samer Haddadin 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 Roslyn Gray, Licensee (LC) and explained the nature of the visit.

During the time of visit, there was one client in care. LPA accompanied with LC 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.
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 between 118.6- and 118.9 degrees Fahrenheit.
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.
During the tour of the kitchen, LPA observed one hammer, 3 sharp screwdrivers and a metal flat scraper in cabinet drawer. LPA also asked LC the whereabouts of sharps and knives; LC stated they were kept on top of a cabinet in one of the rooms and were kept in out of reach however unlocked and in plain view. LPA was able to reach the knives and advised LC to keep all sharps and knives locked and secured out of reach to clients in care.
LPA toured the hallway and observed a Lysol Power Gel in a closed cabinet and was accessible to clients in care. LC immediately locked and secured the Lysol Power Gel.
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 and tripping hazards.(CONTINUE 809C...)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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: 12/05/2024
NARRATIVE
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LPA observed there is seating areas for client’s enjoyment and activities.
LPA observed a fire extinguisher charged and mounted in the entrance of the hallway with last inspection date of August 15th, 2024.
During record review, LPA observed that fire drills are conducted monthly. LPA began review of clients and staff records. All the required documentation was present and current. Client handles their own P&I funds.

Based on the observation made during today’s visit, deficiencies are being citied today in the areas inspected per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted, and a copy of this report was provided to the licensee.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/05/2024 10:30 AM - It Cannot Be Edited


Created By: Samer Haddadin On 12/05/2024 at 09:47 AM
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: 12/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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
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Based on observation, the licensee did not comply with the section cited above in leavingSharps and screw drivers as well as a hammer accessible and within reach which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee locked item and will provide LPA with training staff via e mail within POC due dtae
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in leaving Lysol Power Gel accessible which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/06/2024
Plan of Correction
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Licensee locked item and will provide LPA with training staff via e mail within POC due dtae
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Samer Haddadin
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2024


LIC809 (FAS) - (06/04)
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