306005728-5-17-2022-22-AS-PVEZ-CEJ26M-20220517170722

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005728
Report Date: 05/17/2022
Date Signed: 05/17/2022 05:07:28 PM

Document Has Been Signed on 05/17/2022 05:07 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:	VILLA CELES		FACILITY NUMBER:	306005728
ADMINISTRATOR:	MORALES, MARIO		FACILITY TYPE:	740
ADDRESS:	2933 ANDROS ST		TELEPHONE:	(714) 617-5565
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 3	DATE:	05/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Heidi Skiles - Administrator		TIME COMPLETED:	05:16 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) Patricia Velazquez conducted an unannounced visit to Villa Celes. The purpose of today's visit was to conduct a Required 1 Year inspection focusing primarily on Infection Control. LPA Velazquez was allowed entry into the facility and met with Caregiver (CG) Paulo Martinez. Caregiver Gilda Tejada was also present. Administrator Heidi Skiles arrived shortly after LPA's arrival. The facility is licensed for 6 non-ambulatory residents of which 1 may bedridden. The facility also has a Hospice waiver for 6 residents. There are currently 3 residents living in the facility. The last emergency disaster drill was conducted in January 2022. LPA Velazquez informed Administrator Skiles of the facility's overdue annual fees and provided a copy of the Facility Transaction History including a PIN so the fees can be paid online. Administrator Skiles will submit proof of payment to LPA Velazquez by 5/18/2022. At 2:05 PM LPA Velazquez conducted a tour of the physical plant along with Administrator Skiles. The 1 story home consists of 4 resident bedrooms with 2 bathrooms. There is 1 staff bedroom. The facility also has a living room, dining area, and kitchen. The 3 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. Resident bath towels and personal hygiene supplies were adequately stocked. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 129.7 degrees Fahrenheit in the first bathroom and at 131.7 degrees Fahrenheit in the second bathroom which Administrator Skiles verified. LPA Velazquez inspected the kitchen along with Administrator Skiles. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. LPA observed several unlocked insulin

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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: VILLA CELES	FACILITY NUMBER: 306005728
	VISIT DATE: 05/17/2022

NARRATIVE

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pens located on the door of the refrigerator which Administrator Skiles verified. Per the resident's physician report, the resident cannot administer their own injections and cannot perform their own glucose testing which Administrator Skiles verified. Caregiver Tejada informed LPA Velazquez that she was administering the insulin injections to the resident. Caregiver Tejada is not an appropriately skilled professional. The fire extinguishers were fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Toxins and sharps were locked and inaccessible to residents. The auditory alarms throughout the facility were in operating condition. LPA Velazquez and Administrator Skiles observed Oxygen tanks in resident bedrooms but there were no Oxygen in Use signs present anywhere in the facility. LPA Velazquez and Administrator Skiles observed unlocked Over The Counter (OTC) medications present in resident rooms.

LPA Velazquez along with Administrator Skiles toured the outside grounds. There were no bodies of water present. There was shading and sufficient seating for residents. Walkways around the home were clear of hazards and all of the exit gates did not have a self-closing latch. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit.

Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted with Administrator Heidi Skiles and a copy of this report along with the appeal rights and a copy of the LIC 9098 and LIC 9102s were provided at the time of this visit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 05/17/2022 05:07 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: VILLA CELES	FACILITY NUMBER: 306005728
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degrees F (41 degrees C) and not more than 120 degrees F (49 degrees C).
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 2 bathrooms where the hot water temperature exceeded 120 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/18/2022
	Plan of Correction
1 2 3 4	Licensee to ensure the hot water temperature is always maintained pursuant to regulation and submit written 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: (713) 334-2062
LICENSING EVALUATOR NAME: Patricia Velazquez	TELEPHONE: (949) 236-0556
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3