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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005569
Report Date: 07/31/2024
Date Signed: 07/31/2024 11:42:54 AM


Document Has Been Signed on 07/31/2024 11:42 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:VILLA CHRISTINAFACILITY NUMBER:
306005569
ADMINISTRATOR:ATENCIO, CHRISTINA MFACILITY TYPE:
740
ADDRESS:11651 MARTHA ANN DRTELEPHONE:
(310) 953-5518
CITY:LOS ALAMITOSSTATE: CAZIP CODE:
90720
CAPACITY:6CENSUS: 4DATE:
07/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:22 AM
MET WITH:Administrator, Christina AtencioTIME COMPLETED:
12:00 PM
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 On 7/13/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by staff and granted entry after stating the purpose of the visit. Administrator (AD) Christina Atencio was present to assist with the facility inspection on today's date.

The facility is licensed for six (6) non-ambulatory residents with approved hospice waiver for Five (5) residents. Currently, there are three (3) Hospice residents present during today’s visit.
This is a single story with a two-car garage facility. The facility has six bedrooms and seven full bathrooms
At around 8:30AM, LPA conducted a tour of the physical plant accompanied by Administrator Atencio, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the Resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured between 107.9 to 110.3 degrees F. A comfortable temperature of 74 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. LPA observed Emergency food and water supply. One fire extinguisher was observed as mounted and was fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

CONTINUED ON 809C
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2024
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 2


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: VILLA CHRISTINA
FACILITY NUMBER: 306005569
VISIT DATE: 07/31/2024
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 During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.
LPA observed First Aid Kit was maintained. A working landline phone was operational. The last fire drill was conducted on 7/2/2024. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 7/17/2024 - 7/17/2025. The facility is current on Community Care Licensing annual dues.
A review of four residents (R1-R4) service files and three staff (S1-S3) personnel files revealed to be complete. The facility has the current administrator's certification on file for Christina Atencio # 6033226740 - Expiration 11/13/2024.

No deficiencies during this inspection visit.
An exit interview was conducted with Administrator Atencio, and a copy of the report was provided.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) 703-2870
LICENSING EVALUATOR NAME: Jenifer TirreTELEPHONE: (714) 401-6844
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2