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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004243
Report Date: 08/01/2022
Date Signed: 08/02/2022 06:51:15 AM


Document Has Been Signed on 08/02/2022 06:51 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:VILLA PARK GARDENSFACILITY NUMBER:
306004243
ADMINISTRATOR:AIDA MUSNGI MARTIRESFACILITY TYPE:
740
ADDRESS:18171 E. JAMES ROADTELEPHONE:
(714) 202-5488
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY:6CENSUS: 6DATE:
08/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Josephine Slafkes and Aida MartiresTIME COMPLETED:
01:41 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Josephine Slafkes and explained the reason for the visit. Administrator Aida Martires arrived during the visit. Administrator Martires has a current administrator certificate expiring on 03/23/2023.

At 12:15 PM, LPA toured the facility with Administrator Martires. Facility has 6 residents in care during today's visit with 3 residents on hospice care. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. All rooms are single occupancy. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a visitor sign in sheet. Facility takes resident and staff temperatures daily. Facility has covid precaution postings as well as most department postings. Facility does not have the "Let Us No" poster in the entrance of facility. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. LPA observed an ample supply of emergency food and water. Smoke detectors are hardwired and tested operational during today's visit. Fire extinguishers are fully charged. LPA toured the outside grounds and observed multiple outside visitation areas. LPA observed the locked medication storage area. Residents participate in activities such as exercise and music therapy. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed select resident files during the visit and all files are up to date including emergency information. All residents and staff are vaccinated for Covid-19.

Based on the observations made during today's visit, the following violation is being cited per California Code of Regulations Title 22. Exit interview conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022
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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Document Has Been Signed on 08/02/2022 06:51 AM - 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: VILLA PARK GARDENS
FACILITY NUMBER: 306004243

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Licensees shall prominently post.. complaint information in areas accessible to residents, representatives, and the public.
Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows:
Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475)... The poster that is posted shall be 20" x 26" in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website. This requirement is not being met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Facility does not have the "Let Us No" poster posted in the entrance in regulation size as advised during prior visit to facility. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2022
Plan of Correction
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Licensee to post the "Let Us No" poster in the entrance of the facility in regulation size, "20 X 26" 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 OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 08/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022
LIC809 (FAS) - (06/04)
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