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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002587
Report Date: 05/15/2023
Date Signed: 05/15/2023 02:56:13 PM

Document Has Been Signed on 05/15/2023 02:56 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: 4DATE:
05/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Vidalia Custodio, Consuelo M. RodriguezTIME COMPLETED:
03:10 PM
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This unannounced inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of conducting an Annual Inspection. LPA met with Staff #1 (S1) Vidalia Custodio and discussed the purpose of the inspection. Administrator (AD) Consuelo M. Rodriguez arrived during the inspection.

During the inspection, LPA reviewed Infection Control requirements. At about 12:30PM, LPA and AD conducted a tour of the inside and outside of the facility, common areas, client rooms, kitchen, and garage and observed the following: Structure. This is a one-story home. Facility is a 4-bedroom, 2-bathroom, one-story house with an attached garage that is being used for storage and activities. There is a back yard with a patio cover for the clients. LPA observed 1 staff and 3 clients present at the facility. Client Bedrooms. The 2 client bedrooms are spacious and will easily accommodate the clients’ furnishings. Lamps, chairs, linens, and storage for each client bedroom inspected. Staff Bedrooms. The 2 staff bedrooms are spacious and will easily accommodate the staff’s furnishings. Bathrooms. Bathrooms were clean, faucets and toilets were operational. Water temperature: tested between 118.5 and 118.9 F degrees. LPA inspected all rooms in the facility. Linens & Hygiene Supplies. New linens and fully stocked linen closets were observed. Emergency Phone Numbers & Exit Plan reviewed. Food Service. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. Carbon Monoxide, Smoke Detectors, Fire Extinguisher were observed and tested, including the wired smoke detectors/carbon monoxide detectors. Appliances. Stove burners, microwave, washer, and dryer inspected. Knives: observed secured in the kitchen. Toxins: observed secured in the laundry room and in the kitchen. Medication cabinet is locked. First-Aid Kit and Activity Supplies: observed and available. Facility’s licensing fees are paid. At about 1:00PM, LPA reviewed 4 out of 4 client files and 2 out of 2 staff files, interviewed 3 clients and 1 staff, inspected medications for 4 clients, and inspected client money and ledgers for 4 clients.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2023
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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Document Has Been Signed on 05/15/2023 02:56 PM - It Cannot Be Edited


Created By: Sean Haddad On 05/15/2023 at 02:25 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 SANTIAGO
FACILITY NUMBER: 306002587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records and interview, the licensee has not been conducting emergency disaster drills quarterly but has been doing them twice a year, which poses a potential health and safety risk to persons in care.
POC Due Date: 05/22/2023
Plan of Correction
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Licensee stated they will conduct an emergency disaster drill and submit proof to LPA by POC due date. Licensee stated they will conduct these drills quarterly moving forward.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 05/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/15/2023


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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VILLA SANTIAGO
FACILITY NUMBER: 306002587
VISIT DATE: 05/15/2023
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During the inspection, LPA and AD observed the following: the facility conducts emergency disaster drills twice a year instead of quarterly. LPA provided technical assistance regarding emergency disaster plan.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023
LIC809 (FAS) - (06/04)
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