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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006128
Report Date: 05/22/2023
Date Signed: 05/22/2023 03:02:35 PM


Document Has Been Signed on 05/22/2023 03:02 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:
05/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Staff - Sam Deles TIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Celine De Perio conducted an unannounced case management visit at the facility.

LPA De Perio arrived at facility, explained reason for visit, was greeted and granted entry by staff (S1), who contacted facility administrator (AD) Rowena Marantal-Carrillo about visit. AD Carrillo was unable to be present, however provided consent for S1 to receive and sign report.

For today's visit, there is 1 resident in care, and 1 staff member on duty.

LPA De Perio observed the administrator's certificate for Rowena Marantal-Carrillo which expires on 6/24/23.

LPA De Perio conducted a tour of the physical plant of the facility with S1. Smoke alarms and carbon monoxide detectors were observed to be operational. 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 to be at 107.4 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items, medications, and toxins were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the garage. LPA De Perio observed the emergency disaster and evacuation plan, which is located in the kitchen. Facility had back-up emergency food and water supply, located in the kitchen. LPA De Perio observed that First Aid Kit had all the required components.

For today's visit, a health and safety check was conducted. No health and safety concerns were observed. No citations were issued at this time. An exit interview was conducted with S1. A copy of this report was provided and explained to S1 and AD Carrillo.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3812
LICENSING EVALUATOR NAME: Celine DePerioTELEPHONE: 714-703-2854
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023
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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