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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002587
Report Date: 03/06/2024
Date Signed: 03/06/2024 03:29:20 PM

Document Has Been Signed on 03/06/2024 03:29 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:
03/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Connie RodriguezTIME COMPLETED:
11:35 AM
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit to Villa Santiago. The purpose of today’s visit was to conduct the Annual Required inspection. LPA was allowed entry into the home and met with Administrator Connie Rodriguez. Facility is licensed for 6 non-ambulatory clients and the facility currently has 4 clients. Connie Rodriguez has an Administrator Certificate expiring on 02/25/2024. Administrator provided proof of submittal of certificate renewal.

LPA Lyman along with Administrator Rodriguez toured the facility at 8:50 AM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of two client bedrooms, one client bathroom, two staff rooms, one shared hall bathroom, living room, dining room, and kitchen. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Client bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 115.8 and 116 degrees F in all facility bathrooms. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Common areas were clean and clear of hazards, doorways were free of obstructions. Facility is clean and sanitary. First aid kit had all the required elements including tweezers, thermometer, and scissors. LPA observed a locked storage area for cleaning supplies under the kitchen sink. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. LPA observed sharps locked in a kitchen drawer. Smoke detectors and Carbon Monoxide detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample shaded seating for clients. LPA observed emergency food and water supply in the garage. LPA reviewed the emergency disaster plan during the visit. Plan is thorough and complete. Facility provided documentation of last fire drill conducted on 09/11/2023. Facility provides activities in the form of outings in the community. Facility clients are independent and out in the community. CONTINUED ON LIC 809C DATED 03/06/2024.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VILLA SANTIAGO
FACILITY NUMBER: 306002587
VISIT DATE: 03/06/2024
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At 9:30 AM, LPA reviewed four client files and two staff files. Client files contained required documents including admission agreements, current physician reports and client appraisals. Staff files reviewed contained required documentation of training, health screen/TB, and criminal record clearance. At 10:37 AM, LPA reviewed medication storage and administration. Medications are stored in a locked closet and are audited monthly by staff. Medications are being administered per physician order.






Based on the observations made during today’s inspection, deficiency is 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC809 (FAS) - (06/04)
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Document is an Amendment of Original Document on 04/09/2024 03:31 PM


Created By: Kimberly Lyman On 03/06/2024 at 10:40 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: VILLA SANTIAGO
FACILITY NUMBER: 306002587

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/06/2024

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 record review, the licensee did not comply with the section cited above. Last emergency drill conducted was on 09/11/2023 which poses a potential health, and safety risk to persons in care. CIVIL PENALTY ASSESSED
POC Due Date: 03/20/2024
Plan of Correction
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Licensee to conduct an emergency drill and forward proof to LPA by POC due date.
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2024


LIC809 (FAS) - (06/04)
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