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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005938
Report Date: 08/17/2022
Date Signed: 08/17/2022 01:20:26 PM

Document Has Been Signed on 08/17/2022 01:20 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:VIOLA HOMES ESTATEFACILITY NUMBER:
306005938
ADMINISTRATOR:DANIELA TILLESFACILITY TYPE:
735
ADDRESS:810 W. CIRCLE DRIVETELEPHONE:
(714) 867-7070
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY: 4CENSUS: 4DATE:
08/17/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:04 AM
MET WITH:Nicole Turner, Gazel MontesTIME COMPLETED:
01:35 PM
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This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on self-reported incident reports received in the Orange County Regional Office (OCRO) on 08/02/22, 08/11/22, and 08/15/22 regarding Resident #1 (R1). LPA met with Staff #1 (S1) Nicole Turner. Administrator (AD) Gazel Montes appeared via telephone.

The incident reports stated the following: On 07/28/22, R1 admitted to smoking marijuana outside the facility. On 07/30/22, R1 was advised to follow the house rules but became angry, shouted, slammed doors, damaged facility property, tried to leave the facility, and tried to start fires. Police were called but stated that R1 could leave the facility if they wanted. The facility served R1 with an eviction notice. It was decided that R1 would stay at their family’s house for a few nights. On 08/10/22, while at their family’s house, R1 left their family’s house and stated they are never coming back. Facility notified the police. On 08/12/22, while at their family’s house, R1 attempted suicide by taking 4 times their normal dose of Abilify. R1 was placed on a 5150 at a hospital.

During the inspection, LPA interviewed S1 and AD, requested and reviewed R1’s resident file, and obtained the following information: On 08/15/22, R1 was released from the hospital and immediately left the facility again and since 08/15/22 has been at their family’s house. The facility transferred R1’s medications to their family. The facility is pursuing the eviction of R1 due to their behavior and refusal to follow house rules. LPA provided technical assistance regarding the eviction process. AD stated the facility is working with R1, R1’s family, and the Regional Center of Orange County to find new placement for R1 and to ensure R1’s health and safety until a new placement is found.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE: DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/17/2022
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: VIOLA HOMES ESTATE
FACILITY NUMBER: 306005938
VISIT DATE: 08/17/2022
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During the inspection, LPA reviewed the following items with S1 and AD: The facility’s plan to ensure R1’s health and safety while at the facility. The facility’s plan to ensure R1’s health and safety while at their family’s house. The timeline and history of R1’s behaviors. R1’s assessments. R1’s medications, documentation, and safety precautions.

During the inspection, LPA and S1 conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, and storage shed and observed that the kitchen, resident rooms, bathrooms, and outside areas were clean and organized and LPA observed no health and safety issues. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food is available as required by regulations. LPA observed hallways and walkways were free of obstruction. LPA observed medications locked in the medication cabinet and knives locked in the outdoor shed.

During the inspection, LPA and S1 observed the following: unsecured toxins including bleach and pesticide in the non-lockable closet in the laundry room. During the inspection, S1 properly secured all of these items and LPA confirmed.

Facility representative was advised that at this time further investigation may be required. Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Sean Haddad
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/17/2022 01:20 PM - It Cannot Be Edited


Created By: Sean Haddad On 08/17/2022 at 01:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: VIOLA HOMES ESTATE
FACILITY NUMBER: 306005938

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2022
Section Cited
CCR
80087(g)

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80087 Buildings and Grounds: (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidenced by:
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Licensee immediately secured the toxins and other dangerous items during today's inspection and LPA confirmed.
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Based on observation, the licensee did not ensure toxins were inaccessible to residents in the laundry room, which poses an immediate health and safety risk to persons in care.
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POC CLEARED

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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:Armando J Lucero
LICENSING EVALUATOR NAME:Sean Haddad
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022


LIC809 (FAS) - (06/04)
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