306004459-5-22-2024-22-AS-ARJR-D5HUNR-20240522154418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004459
Report Date: 05/22/2024
Date Signed: 05/22/2024 03:44:25 PM

Document Has Been Signed on 05/22/2024 03:44 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	JOHN VILLA'S HOMECARE 2		FACILITY NUMBER:	306004459
ADMINISTRATOR:	VILLA DIAZ		FACILITY TYPE:	740
ADDRESS:	811 ST. CLAIR		TELEPHONE:	(714) 760-4693
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 3	DATE:	05/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Arthur Aguas-Caregiver, Villa Diaz-Licensee		TIME COMPLETED:	03:57 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

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Arthur Aguas. Administrator (AD) Villa Diaz arrived shortly after.

For today’s visit, LPA observed a total of three residents in care and two staff members on duty.

LPA observed the Administrator's Certificate for facility AD Juan Diaz which expires on 05/24/2024.

LPA Ramirez toured the interior and exterior portions of the facility with AD Diaz. The facility is a single level structure and is licensed for six non-ambulatory residents, of which two may be on hospice and zero bedridden. There are a total of four bedrooms, of which four are resident bedrooms. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of two restrooms of which one is for staff and one is for residents. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 109.0-111.5 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located by the kitchen.

CONTINUED ON LIC809-C..

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

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 3

Document Has Been Signed on 05/22/2024 03:44 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JOHN VILLA'S HOMECARE 2	FACILITY NUMBER: 306004459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed ready to dispense medication in small labeled containers.
	POC Due Date: 05/23/2024
	Plan of Correction
1 2 3 4	Licensee to provide in-service medications training and provide proof 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) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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 HOMECARE 2	FACILITY NUMBER: 306004459
	VISIT DATE: 05/22/2024

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
26
27
28
29
30
31
32

LPA Ramirez observed the emergency disaster and evacuation plan, which is posted by the entrance hallway. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA Ramirez observed a shaded area, patio furniture, and the grounds were free of any hazards. There is 1 gate in the backyard, which both is self-closing and self-latching. No bodies of water were observed.

LPA reviewed three resident files and two staff files. LPA interviewed residents and staff present.

For today's visit one deficiency was issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Diaz.

A copy of this report was provided at the time of exit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3