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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006128
Report Date: 08/04/2022
Date Signed: 08/04/2022 04:15:50 PM


Document Has Been Signed on 08/04/2022 04:15 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:VILLAS BY DOCTOR ROYAFACILITY NUMBER:
306006128
ADMINISTRATOR:JAFARI-HASSAD, ROYAFACILITY TYPE:
740
ADDRESS:23232 LA VACA STTELEPHONE:
(516) 322-3095
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY:6CENSUS: 1DATE:
08/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Facility Administrator- Mavivien MiglioriniTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced Case Management visit. During today's visit, LPA De Perio met with facility administrator (AD) Mavivien Migliorini, and AD Roya Jafari-Hassad via phone and manually handed AD Migliorini and discussed about the following documents and reporting requirements:
  • Mandated Reporter Timeline
  • LIC 624 (Unusual Incident/Injury Report)
  • SOC 341 (Report of Suspected Dependent Adult/Elder Abuse)
  • LIC 624A (Death Report)
  • COVID Script
  • LIC 610 E (Emergency and Disaster Plan)
  • LIC 500 (Personnel Report)
  • LIC 602 (Physician's Report)

LPA De Perio also discussed about regulations regarding:
  • Staff Trainings
  • Administrator Requirements
  • Background Clearances
  • First-Aid/CPR

LPA De Perio also reiterated to both AD's the importance of utilizing the Guardian forum, staff associations and clearances. Copies of the regulations were also provided for AD's references.
There were no deficiencies issued during this Case Management visit. No citation was issued during this visit.
An exit interview was conducted with AD Migliorini and a copy of this report was provided to the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2022
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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