306004795-7-20-2022-22-AS-ETAA-CGHQKH-20220720121421

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004795
Report Date: 07/20/2022
Date Signed: 07/20/2022 12:14:35 PM

Document Has Been Signed on 07/20/2022 12:14 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	WESTMINSTER VILLA		FACILITY NUMBER:	306004795
ADMINISTRATOR:	PATTY OSUNA		FACILITY TYPE:	740
ADDRESS:	13881 DAWSON STREET		TELEPHONE:	(714) 534-7880
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92843
CAPACITY:	200	CENSUS: 118	DATE:	07/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Patty Osuna, Alexis Jones, Juan Godoy, Moncerrat Pasillas		TIME COMPLETED:	12:30 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) Edward Tapia made an unannounced required annual inspection at this facility. LPA met with Administrator Patty Osuna and Assistant Administrator Alexis Jones and stated the purpose of this visit. Staff Juan Godoy and Moncerrat Pasillas assisted with the visit. The facility is a two-level structure licensed for one hundred non-ambulatory and one hundred ambulatory with a hospice waiver for ten. This facility offers Residential Care for the Elderly. At about 9:35 am, LPA Tapia was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, LPA observed residents in care and staff members on duty. LPA toured the interior and exterior portions of the facility. Resident rooms were selected at random for inspection. On the first-floor resident rooms (112,127,115,117,120,119) were selected for inspection. On the second-floor resident rooms (201,226,223B, 222,207) were inspected for selection. Resident rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Resident rooms did have private restrooms. Resident bathrooms were observed to be in good repair and provided with grab bars and hot water was measured between 111.9 degrees and 124.7 degrees Fahrenheit. Administrator was made aware of water temperature regulations. LPA also notice handing washing signs throughout the facility. LPA Tapia notice PUB 475 poster posted in a prominently locations, but not in the correct size. LPA Tapia provided the correct size for the PUB 475 poster. LPA was provided a report for smoke detectors and carbon monoxide alarms being tested on 06/29/2022. Facility met the minimum two-day supply of perishable and seven-day supply of non-perishable food stock requirements, cleaning supplies and sharp items were inaccessible to residents in care. Facility had adequate supplies of personal protective equipment in place. Fire extinguishers were observed to be charged and operational. For the exterior portion, facility had an outside patio which is used as a smoking section with furniture in good repair; and grounds were free of tripping hazards.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

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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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: WESTMINSTER VILLA	FACILITY NUMBER: 306004795
	VISIT DATE: 07/20/2022

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Kitchen was in good repair and in a separate room inaccessible to residents. LPA Tapia noticed while reviewing canned foods in the kitchen some did not have an expiration date. Administrator was made aware of this finding and items removed immediately. Dining room was in good repair and seating arrangements are 2 persons per table. Facility also had a Movie room, activity room and physical therapy room all of which were in good repair. LPA Tapia reviewed the COVID 19 mitigation plan and Emergency Disaster plan of the facility. LPA discussed Assembly Bill 665 that requires a licensee of any adult care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For this visit, no deficiency was noted in areas observed and no Civil Penalty were issued. No citation was issued. One advisory along with a technical violation was issued today.

LPA Tapia conducted an exit interview with Administrator Patty Osuna and a copy of this report was explained and left at the facility.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Edward Tapia	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC809 (FAS) - (06/04)

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