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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002587
Report Date: 04/13/2022
Date Signed: 04/13/2022 03:43:40 PM

Document Has Been Signed on 04/13/2022 03:43 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 SANTIAGOFACILITY NUMBER:
306002587
ADMINISTRATOR:CONSUELO M. RODRIGUEZFACILITY TYPE:
735
ADDRESS:817 E. 20TH ST.TELEPHONE:
(714) 542-4126
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY: 6CENSUS: 3DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Consuelo RodriguezTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez conducted this unannounced required/annual inspection. LPA was greeted by caregiver Vidalia Custodio and discussed the purpose of the inspection. Administrator (AD) Consuelo Rodriguez was contacted by phone and arrived a short time later at 2:32pm. During the inspection LPA and AD conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and garage and observed the following:

This is a single-story house with four bedrooms, and two bathrooms, with one bedroom being occupied by live in staff. During the inspection, LPA observed there was one staff present with two residents in care at the home and one away at day program. Residents were observed relaxing in their respective rooms. LPA inspected common areas, resident rooms, kitchen, and garage and observed 2-day supply of perishable foods and a 7-day supply of non-perishable food is available. LPA observed hallways and walkways were free of obstruction.

LPA reviewed and confirmed facility policies and practices regarding resident screening, staff screening, visitation, COVID-19 surveillance testing, COVID-19 clearance testing, quarantine, isolation, cohorting, infection control training, PPE, staffing and staffing shortages.

Based on the observations made during today’s inspection no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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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