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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006128
Report Date: 09/01/2022
Date Signed: 09/01/2022 10:59:00 AM


Document Has Been Signed on 09/01/2022 10:59 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
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: 0DATE:
09/01/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:Roya HassadTIME COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Celine De Perio made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 08/09/2022. LPA De Perio explained reason for visits and was greeted and granted entry by facility administrator (AD) Roya Hassad.

For today's visit, LPA De Perio verified that there are currently no residents in care and no staff present.

On 08/09/22, facility 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.

*Deficiency cited under Title 22 Regulation 87309(a) pertaining to Storage Space has been CLEARED. Licensee has secured noted items and now has a designated locked location for disinfectants, cleaning solutions, poisons, and other items. Licensee has complied with the terms of the POC.

On 08/09/22, licensee failed to ensure that staff present at the facility, obtained a criminal record clearance or exemption prior to working in the facility.

* Deficiency cited under Title 22 Regulation 87355(b) Criminal Record Clearance has been CLEARED. Licensee has submitted and provided documentation indicating clearance for staff who were present on 08/09/2022 and have completed a background check. Licensee has complied with the terms of the POC.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/01/2022
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: 09/01/2022
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On 08/09/2022, 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.

*Deficiency cited under Title 22 Regulation 87705(f)(1) pertaining to Care of Persons with Dementia has been CLEARED. Licensee has secured noted items and now has a designated locked location for knives, sharps and scissors. Licensee has complied with the terms of the POC.

On 08/09/2022, 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. LPAs observed and verified by AD, that facility did not have heath screening certificates for staff present.

* Deficiency cited under Title 22 Regulation 87411(f) Personnel Requirements – General has been CLEARED. Licensee has submitted and provided documentation indicating that employees present on 08/09/2022 completed a health screening report. Licensee has complied with the terms of the POC.

On 08/09/2022, facility failed to provide appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

* Deficiency cited under Title 22 Regulation 87411(c)(1) Personnel Requirements – General has been CLEARED. Licensee has submitted and provided documentation indicating that employees present on 08/09/2022 completed a first-aid training. Licensee has complied with the terms of the POC.

LPA De Perio conducted an exit interview with AD Hassad and a copy of this report and Letter of Cleared Deficiency has been provided to the facility.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2022
LIC809 (FAS) - (06/04)
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