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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004456
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:35:13 PM

Document Has Been Signed on 10/05/2023 03:35 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:VILLA LURENFACILITY NUMBER:
306004456
ADMINISTRATOR:BRIAN BUENVIAJEFACILITY TYPE:
735
ADDRESS:13749 E. CREWE STREETTELEPHONE:
(562) 941-3813
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY: 62CENSUS: 63DATE:
10/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Bryan Buenviaje – Administrator TIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced case management visit regarding an incident that was not reported to the Community Care Licensing Department in a timely manner. LPA met with Bryan Buenviaje (Administrator) and explained the reason for the visit.

On the evening of 09/24/2023, C1 left the facility and did not return. The facility filed a missing person report the following morning. The facility did not notify or submit an incident report to the Community Care Licensing (CCLD). On 09/28/2023, CCLD was made aware of this incident because a complaint was received.

The deficiency cited is documented on the LIC809D. Exit interview held and a copy of the report and appeal was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Luis Mora
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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 10/05/2023 03:35 PM - It Cannot Be Edited


Created By: Luis Mora On 10/05/2023 at 02:46 PM
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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA LUREN
FACILITY NUMBER: 306004456

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/12/2023
Section Cited
CCR
80061(b)(E)

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(b) Upon the occurrence...a written report...shall be submitted to the licensing agency within seven days following the occurrence of such event. (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client...
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Facility is to ensure that Title 22 Section 80061 regulations are met at all times. Additionally, an in-service training is to be conducted regarding reporting requirements with all staff and submit proof of training to CCLD by 10/12/2023.
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This regulation has not been met as evidenced by:

Based on interviews and records review, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. The facility failed to report an incident report to CCLD.
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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:Wei Siew Ho
LICENSING EVALUATOR NAME:Luis Mora
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023


LIC809 (FAS) - (06/04)
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