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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005728
Report Date: 08/12/2024
Date Signed: 08/12/2024 11:18:40 AM

Document Has Been Signed on 08/12/2024 11:18 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 CELESFACILITY NUMBER:
306005728
ADMINISTRATOR/
DIRECTOR:		MORALES, MARIOFACILITY TYPE:
740
ADDRESS:2933 ANDROS STTELEPHONE:
(714) 486-1133
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 5DATE:
08/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Kian PascualTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 8/12/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA was greeted and granted entry by Caregivers, Marvin Cristobal and Abigail Benedicto who were informed of the purpose of LPA's visit. Administrator, Kian Pascual arrived during the visit and was also informed of the purpose of LPA's visit. The facility has a fire clearance for six (6) non-ambulatory elderly residents, of which one (1) may be bedridden. The facility also has an approved hospice waiver for six (6) and LPA was informed two (2) residents are currently receiving hospice services at the facility.

LPA toured the facility with Caregiver Benedicto and observed the facility is made up of a one-story home with four (4) resident bedrooms, two (2) bathrooms, a staff room, kitchen and dining room and living room. During the tour, Caregiver Cristobal tested one (1) of the smoke alarms/carbon monoxide detectors and LPA observed it to be operational. LPA also observed charged fire extinguishers mounted throughout the facility. Indoor and outdoor passageways were free of obstruction. The facility has outdoor shaded seating for the residents in care. There were no bodies of water observed on the premises. Medications are secured in a locked kitchen cabinet. Resident bedrooms had the required furniture and lighting. Bathrooms had grab bars near the toilet and in the showers. LPA observed a hallway closet filled with clean linens and cabinets filled with Personal Protective Equipment, incontinent and hygiene supplies. The facility had a 2-day supply of perishable foods and 7-day supply of non-perishable food items. The facility also has a fireplace in the living room that is adequately screened to make it inaccessible for the residents in care. Resident files reviewed had signed admission agreements and physician reports. Staff present have a criminal record clearance and valid first aid/CPR certification. LPA called the facility's landline and observed it was operational. Long Term Care Ombudsman, facility sketch and personal rights information are posted near the front entrance.

During today's visit, LPA did not issue any deficiencies. An exit interview was conducted where this report was reviewed and provided to Administrator Pascual.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE: DATE: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/12/2024
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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