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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006192
Report Date: 09/30/2024
Date Signed: 09/30/2024 06:21:02 PM

Document Has Been Signed on 09/30/2024 06:21 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:VIOLA HOMES ESTATEFACILITY NUMBER:
306006192
ADMINISTRATOR/
DIRECTOR:		SNETTER, MIATTAFACILITY TYPE:
735
ADDRESS:15770 AZALEA WAYTELEPHONE:
(323) 304-4620
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY: 4CENSUS: 3DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Stephanie AguilarTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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Licensing Program Analysts (LPAs) Michael Tea conducted an unannounced visit. The purpose of today’s visit was to conduct the Annual Required inspection. LPA Tea was greeted and granted entry into the facility by DSP staff, Hailey Camacho and explained the reason for the visit. House Manager (HM) Stephanie Aguilar arrived shortly to assist with the visit. Facility is licensed for 4 ambulatory clients. Currently there are three clients.

LPA Tea and HM Aguilar toured the facility at around 2:00 PM. LPA toured the physical plant, checked food service, and the first aid kit. The home consists of 4 client bedrooms, 2 bathrooms, living room, dining room, and kitchen and attached garage. LPA observed smoke detectors/carbon monoxide in client bedrooms and they are operational. There are no smoke detectors in common areas. LPA advised facility to install smoke detectors in the common area for the safety of clients. Client bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Just furniture and facility rooms are worn out from wear and tear and client behavior. Water temperature measured at 118.4 F degrees. Client bath towels, toiletries and personal hygiene supplies were adequately stocked at time of visit. Doorways were free of obstructions. First aid kit had all the required elements including bandages, tweezers, thermometer, and scissors. Kitchen was inspected. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. There are no sharps in the facility, they have plastic knives and butter knives. LPA also observed toxin substances to be locked and inaccessible to clients in care locked away in a cabinet in the garage where clients have inaccessibility or unless supervised when clients are present in the garage.. The fire extinguisher in the kitchen was fully charged. Kitchen appliances are operational during today's visit. LPA toured the outside grounds and there is ample seating with shade in the front yard area. There is no backyard space. LPA observed emergency food in the kitchen and water supply in the garage. Facility provides activities based on clients interests, in the form of outdoor activities such as going out for walks and doing exercises, playing basketball at the park and going on outings like to the store and the beach.

Continuation of annual inspection on LIC809-C
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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Document Has Been Signed on 09/30/2024 06:21 PM - It Cannot Be Edited


Created By: Michael Tea On 09/30/2024 at 05:09 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: 306006192

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on LPA's observation former resident's room needs to be repaired and furniture needs to be placed. Male client's room furniture needs to be repaired and walls clean or painted again, and closet floorboard needs to be repaired. Bathroom needs cleaning and maintanance, bathroom cabinets need to be replaced or resurfaced. Bathroom has hole in the wall that needs to be patched. Hallway cabinet needs to have a door knob replaced. Living room furniture needs to be replaced and all worn out. Kitchen stove burner is in disrepair. This could pose a potential health and safety risk to clients in care.
POC Due Date: 10/14/2024
Plan of Correction
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Facility will show proof of work orders or progress of repairs by POC due date to LPA
Type B
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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 Based on LPA's review of records there is no needs and service plan on file. This could be a potential health and safety risk to clients in care.
POC Due Date: 10/14/2024
Plan of Correction
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Facility/Licensee will show completed apprisals and needs and service plans for clients by POC due date to LPA
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:Alisa Ortiz
LICENSING EVALUATOR NAME:Michael Tea
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VIOLA HOMES ESTATE
FACILITY NUMBER: 306006192
VISIT DATE: 09/30/2024
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At the time of the visit, clients were coming back from the day program and doing chores around the house.
LPA Tea reviewed three client files and one staff file. There were discrepancies noted in the review of resident and staff files.

LPA reviewed medication storage and administration. Medications are stored in a locked cabinet in the kitchen area. Medications are being administered per physician order. LPA interviewed residents regarding their quality of care and spoke to staff present regarding care provided. P&I Funds are secured in a locked cabinet with the medication. P&I Funds were checked and meet department standards.

The following deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with House Manager Stephanie Aguilar and a copy of these reports were given to the facility along with a copy of the LIC 858; 859;809-D, 9102 and Appeal Rights
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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