306002964-8-23-2022-22-AS-JCHO-CHKTAK-20220823143341

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306002964
Report Date: 08/23/2022
Date Signed: 08/23/2022 02:33:50 PM

Document Has Been Signed on 08/23/2022 02:33 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:	JOHN VILLA'S HOME CARE I		FACILITY NUMBER:	306002964
ADMINISTRATOR:	VILLA D. DIAZ		FACILITY TYPE:	740
ADDRESS:	219 HANOVER		TELEPHONE:	(714) 435-9257
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 6	DATE:	08/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:28 PM
MET WITH:	Villa Diaz, Juan Diaz		TIME COMPLETED:	02:48 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 08/23/2022, Licensing Program Analyst (LPA) Jessica Cho conducted an unannounced visit to John Villa's Home Care I. The purpose of today's visit was to conduct a Required 1 Year focusing primarily on the Infection Control. At 12:30pm, LPA Cho was allowed entry into the facility and met with Licensee/Administrator (Admin) Villa Diaz after completing the Coronavirus 2019 (COVID-19) screening procedure. Caregiver Princess Diaz was also present at this time. Administrator Juan Diaz arrived at the facility around 12:47pm to assist with the tour. As of today, there are no active COVID-19 cases in the facility. Facility screens and documents temperatures for visitors on a sign in sheet. LPA observed the required COVID-19 precautionary signs posted on the front door and throughout the facility. LPA observed the Complaint Poster (PUB475) in the size of 9"x18" which did not meet the size requirement. The facility is licensed for six non-ambulatory residents and has a hospice waiver for four. There are currently six residents living in the facility of which four are receiving hospice care. The Administrator's Certificate for Villa Diaz expired on 06/22/2022 and on 05/24/2024 for Juan Diaz. Admin Juan provided proof of receipt for Villa's Administrator's Certification application which was submitted on 06/16/2022. At 12:42pm, LPA Cho conducted a tour of the physical plant along with Administrator Juan. The single story home consists of three resident bedrooms with one resident bathroom. There are two staff bedrooms and one staff bathroom. The facility also has a living room, dining area, kitchen, and an attached two car garage. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathroom was checked. Toilet and water faucet worked properly, grab bars were secure, shower was free of mold/mildew, and a non-skid mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked including paper towel and hand soap. LPA observed hand washing signs in all bathrooms. LPA Cho tested the hot water temperature in the resident bathroom and the temperature measured at 111.0 degrees Fahrenheit in the Bathroom #1.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

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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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: JOHN VILLA'S HOME CARE I	FACILITY NUMBER: 306002964
	VISIT DATE: 08/23/2022

NARRATIVE

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LPA Cho inspected the kitchen along with Admin Juan. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. The auditory alarms throughout the facility were in operating condition.

LPA Cho toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards, and the exit gate was self-closing and self-latching. There were no security bars or weapons on the premises. A locked shed was located in the yard that stored gardening supplies.

LPA Cho reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E). Facility has a plan for COVID-19 testing residents and staff as well as a plan for isolation as needed. Facility has back-up emergency food and water supply. The First Aid Kit met all the required components, and the facility had sufficient PPEs. No resident or staff files were reviewed at the time of this visit. LPA reviewed the COVID-19 mitigation plan of the facility as well as Assembly Bill (AB) 665. This bill would require residential facilities serving adults, residential care facilities for persons with chronic life-threatening illness, and residential care facilities for the elderly with existing internet service to provide at least one internet access device that can support real-time interactive applications, is equipped with video conferencing technology, and is dedicated for client or resident use. The facility does have an existing internet service and provides the residents a smart phone upon request.

LPA provided the following guidance: to obtain and post the Complaint Poster (PUB475) that meets the size requirement, to submit the Infection Control Plan (LIC9282), and to keep the facility free of flies and fruit flies. In addition, LPA reminded the importance of staying abreast with CCLD's COVID-19 guidance by reviewing and printing the Provider Information Notices (PINs) as well as by attending the CCLD Informational Calls. The PINs can be accessed at: www.ccld.ca.gov. In addition, Admin Juan acknowledged and agreed to submitting the Infection Control Plan (LIC9282) and the Emergency Infection Control Plan pertaining to the Monkeypox guidelines by 09/02/2022.

Based on the observations made during today's visit, a deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Administrators Juan and Villa Diaz, and a copy of this report (including LIC809, LIC809C, LIC809D, LIC9102s, and the appeal rights) were provided.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/23/2022 02:33 PM - It Cannot Be Edited

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: JOHN VILLA'S HOME CARE I	FACILITY NUMBER: 306002964
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)(1)

80087 Building and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview of Administrator Juan Diaz, flies and fruit flies were observed in the facility which poses a potential Health, Safety, or Personal Rights risk to persons in care.
	POC Due Date: 08/26/2022
	Plan of Correction
1 2 3 4	Licensee to immediately dispose uneaten food and to purchase addtional fly traps and to sumbit proof of correction to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica Cho	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022

LIC809 (FAS) - (06/04)

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