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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004440
Report Date: 08/23/2021
Date Signed: 08/23/2021 12:23:36 PM

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 AT PLEASANT HILLS, THEFACILITY NUMBER:
306004440
ADMINISTRATOR:CASEY VILLAVERDEFACILITY TYPE:
740
ADDRESS:938 JOYCE DRIVETELEPHONE:
(714) 582-2345
CITY:BREASTATE: CAZIP CODE:
92821
CAPACITY:6CENSUS: 5DATE:
08/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Amy GulapaTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Ruth Martinez conducted an unannounced visit for the purpose of conducting a required annual visit. LPA arrived at the facility was greeted and granted entry into the facility by caregiver. LPA spoke to Administrator via telephone and explained the nature of the visit.

LPA Martinez accompanied by caregiver toured the facility. There are five residents in care and no active covid-19 cases. LPA observes three residents in living room and two in their bedrooms. Residents appeared clean and well taken care of. LPA observed a check in station in the main entry of the facility with logs per covid guidelines. LPA observed required department postings, covid-19 precautionary postings, and hand washing signs in the restrooms. All restrooms observed to have soap/sanitizer and appeared clean. Residents bedrooms appeared clean and sanitary with all required components. Facility is taking covid-19 precautionary measures daily. LPA observed the emergency disaster and evacuation plan posted. Facility has back-up emergency food and water supply as well as PPE supplies. LPA toured the outside and observed a large seating area for resident which is used for outdoor visitations as well. LPA observed sanitizer stationed in the outdoor seating area. Facility has completed the LIC808 Mitigation Plan and LPA Martinez approved the plan on site.

Based on the observations made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted, this report was reviewed with facility representative and a copy of this report was provided and left at facility.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021
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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