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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002964
Report Date: 08/03/2026
Date Signed: 08/03/2026 11:44:23 AM

Document Has Been Signed on 08/03/2026 11:44 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:JOHN VILLA'S HOME CARE IFACILITY NUMBER:
306002964
ADMINISTRATOR/
DIRECTOR:		VILLA D. DIAZFACILITY TYPE:
740
ADDRESS:219 HANOVERTELEPHONE:
(714) 435-9257
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 3DATE:
08/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Villa Diaz, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On August 3, 2026, Licensing Program Analysts (LPAs) Taylor Simerly and Joseph Alejandre made an unannounced visit to conduct a required annual visit. LPAs were greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 4 residents and the home currently has 5 residents (2 are currently in the hospital), zero residents are on hospice. Administrators (AD) Villa Diaz and Juan Diaz Jr. were present for the visit. AD Villa Diaz has a current administrator certificate on file from June 23, 2026 to June 22, 2028. The facility has a valid liability insurance from July 1, 2026 to July 1, 2027.

The home consists of 3 resident bedrooms, 2 staff rooms, living room, dining room, and kitchen as well as 3 bathrooms. The home has an attached two car garage that is inaccessible to residents. The living room has a two sided fireplace that has a screen. In the garage, there was a three day emergency supply of food and water. The LPAs toured the shed in the backyard that is used for storage and is locked. The backyard includes a shaded seated area for residents.

LPAs and the ADs toured the physical plant. There were no bodies of water or obstructions on the premises. LPAs inspected residents’ bedrooms and bathrooms. The beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. The bathrooms were found to be within Title 22 regulations and were operational. Smoke and carbon monoxide detectors were in operable condition. The water temperature ranged from 117.5°F to 119.1°F.

The evaluation Report continues on the next page, LIC 809-C, providing further details of the inspection findings.
Alfonso Iniguez
Taylor Simerly
DATE: 08/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/03/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 08/03/2026 11:44 AM - It Cannot Be Edited


Created By: Taylor Simerly On 08/03/2026 at 11:30 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: JOHN VILLA'S HOME CARE I
FACILITY NUMBER: 306002964

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and 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 in which the LPA reviewed the records and the last drill was on April 22, 2026, which was not in the last quarter. poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2026
Plan of Correction
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The Licensee will send LPA Simerly proof of an updated drill by the 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.
Alfonso Iniguez
NAME OF LICENSING PROGRAM MANAGER:
Taylor Simerly
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2026


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: JOHN VILLA'S HOME CARE I
FACILITY NUMBER: 306002964
VISIT DATE: 08/03/2026
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During the visit, LPAs observed that the facility was appropriately furnished. Storage areas for personal hygiene were in place. Cleaning supplies, toxins, and sharp objects were stored in a way that made them inaccessible to residents in care. The kitchen was inspected, and there were sufficient perishable and non-perishable food available, which was adequately maintained. All fire extinguishers were charged and operable. The last Fire/Disaster Drills were conducted on April 22, 2026. LPAs inspected the first aid kit and it was missing bandages and a first aid manual.

A review of (5) residents' service files and (3) staff personnel files was conducted. LPA reviewed (3) Medication Administration Records (MARs) and found no discrepancies.

LPAs observed the facility's infection control practices. All mandated inspection control posters were displayed throughout the facility.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8. See D page for details. Technical violations were also issued at this time.

An exit interview was conducted, and a copy of the Facility Evaluation Report and appeal rights were provided to Villa Diaz, Administrator.

NAME OF LICENSING PROGRAM MANAGER: Alfonso Iniguez
NAME OF LICENSING PROGRAM ANALYST: Taylor Simerly
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2026
LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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