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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006128
Report Date: 08/09/2022
Date Signed: 08/09/2022 02:34:20 PM


Document Has Been Signed on 08/09/2022 02:34 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:
08/09/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Facility Administrator- Mavivien MiglioriniTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Celine De Perio and Albert Marin conducted an unannounced required post licensing visit in this facility and informed administrator (AD) Mavivien Migliorini about the reason for the visit. Prior to being granted entry into the facility, AD Migliorini took LPAs temperature. AD Migliorini also contacted Licensee Roya Jafari-Hassad who was unable to be present during the visit, but was present via telephone call. As of today, there are no active COVID-19 cases in the facility as verified. LPAs observed the required COVID-19 precautionary signs posted by the main entrance door. The PUB475 "See Something, Say Something" poster was observed in the kitchen.

LPAs De Perio and Marin toured the interior and exterior portions of the facility with AD Migliorini. The facility is a single level structure and is licensed for a capacity of six non-ambulatory residents who are the age of 60 years and over, of which 1 may be bedridden, and 6 may be on hospice.

Currently, there are a total of 1 resident in care, who is not bedridden and not on hospice. All bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector were tested and operational. At 10:24 AM, LPA De Perio and Marin observed that auditory exit and entry alarms were not operational. Per licensee interview, it was informed that the alarm goes straight to cell phone application.

The restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature in restrooms were measured at 109.9 degrees Fahrenheit. At 10:26 AM, LPA De Perio and Marin observed toxins and disinfectants in an unlocked bathroom cabinet.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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: VILLAS BY DOCTOR ROYA
FACILITY NUMBER: 306006128
VISIT DATE: 08/09/2022
NARRATIVE
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Facility met the minimum two-day perishable food supplies. Fire extinguisher was charged, mounted and located in the garage.

For the exterior portion, LPA De Perio and Marin observed patio furniture under shading, and the grounds were free of any hazards. There is one gate in the backyard, which is self-closing and self-latching. LPA De Perio observed the emergency disaster and evacuation plan, which is posted in the kitchen.

LPA De Perio observed that First Aid Kit had all the required components. Medications were locked in the laundry room. At 10:34 AM, LPA De Perio and Marin observed multiple toxins and disinfectants in an unlocked kitchen cabinet located under the sink. At 10:34 AM, LPA De Perio also observed knives and sharps in an unlocked kitchen drawer.

LPA De Perio verified the Coronavirus 2019 (COVID 19) mitigation plan of the facility with AD Migliorini. LPA De Perio and Marin discussed Assembly Bill 665 requires that a licensee of any adult or senior care residential facility that has internet service provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use.

For today's visit deficiencies, citations and civil penalty and appeal rights were issued per Title 22 Division 6 of the California Code of Regulations. See LIC809-D, and LIC421BG.

LPA De Perio and Marin advised AD Migliorini and Licensee Hassad to use the general email address: CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

LPA De Perio conducted an exit interview with AD Migliorini and Licensee Hassad via telephone call 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: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 08/09/2022 02:34 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: VILLAS BY DOCTOR ROYA
FACILITY NUMBER: 306006128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
87309 Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms, and other items which could post a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee failed to lock disinfectants, cleaning solutions, poisons, and other items which could post a danger. LPA observed cleaning supplies and disinfectants stored in an unlocked cabinet located under the kitchen sink and bathroom. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2022
Plan of Correction
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Licensee will lock and ensure that all toxins and disinfectants are inaccessible to residents in care. AD removed all disinfectants and transferred them to locked room. Threat reduced. Licensee will comply with the POC on or by 8/23/2022 and submit proof to assigned LPA and Community Care Licensing.
Type A
Section Cited
CCR
87705(f)(1)
87705(f)(1) Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee failed to lock knives, and other items that could constitute a danger to the resident(s) which could post a danger. LPA observed knives, sharps and scissors in an unlocked kitchen cabinet. AD removed all sharp items and knives in a locked room. Threat reduced. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2022
Plan of Correction
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Licensee will lock and ensure all sharps and knives are inaccessible to residents in care. Licensee will comply with the POC on or by 8/23/2022 and submit proof to assigned LPA and Community Care Licensing.

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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 08/09/2022 02:34 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: VILLAS BY DOCTOR ROYA
FACILITY NUMBER: 306006128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(b)
87355 Criminal Record Clearance

(b) Prior to the Department issuing a license, the applicant, administrator and any adults other than a client, residing in the facility shall have criminal record clearance or exemption.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, discussions, and record review, the licensee did not comply with the section cited above as LPAs observed no clearance for staff present at the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2022
Plan of Correction
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Licensee will ensure that all staff members and volunteers in the facility will recieve clearance prior to working in the facility. Licensee sent staff 1 for fingerprinting and background check. Threat reduced. As proof of correction, licensee will provide the completed documents indicating clearance on or by 8/23/2022 to assigned LPA and Community Care Licensing.

Civil penalty assessment was issued.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 9


Document Has Been Signed on 08/09/2022 02:34 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: VILLAS BY DOCTOR ROYA
FACILITY NUMBER: 306006128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
87411 Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review and interview, facility failed to provide health screening report performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. At 12:00 PM, LPAs observed and verified by AD, that facility did not have heath sceening certificate for AD and Staff 1. This poses potential health and safety concerns on resident in care.
POC Due Date: 08/23/2022
Plan of Correction
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Licensee will ensure that all employees have a health screening report prior to, or 7 days after employment, and should be readily available to review at all times. Licensee will provide proof of correction on or by 8/23/2022 to assigned LPA and Community Care Licensing.

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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 5 of 9


Document Has Been Signed on 08/09/2022 02:34 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: VILLAS BY DOCTOR ROYA
FACILITY NUMBER: 306006128

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee failed to provide appropriate training in first aid from persons qualified by such agencies as the American Red Cross. LPAs observed and as verified with AD that Staff 1 had no copy of first aid training as provided by qualified agencies such as American Red Cross. This poses potential risks on health and safety of residents in care.
POC Due Date: 08/23/2022
Plan of Correction
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As plan of correction, licensee will ensure that all staff recieve the appropriate first aid training from qualified agencies.As proof of correction, licensee will provide copies of validated trainings on or by 8/23/2022 to assigned LPA and Community Care Licensing.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 6 of 9