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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006387
Report Date: 03/11/2025
Date Signed: 03/11/2025 01:15:47 PM

Document Has Been Signed on 03/11/2025 01:15 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:ANAHEIM VILLAFACILITY NUMBER:
306006387
ADMINISTRATOR/
DIRECTOR:		PARK, YOUNGFACILITY TYPE:
740
ADDRESS:3411 W BALL ROADTELEPHONE:
(714) 821-9660
CITY:ANAHEIMSTATE: CAZIP CODE:
92804
CAPACITY: 210CENSUS: 75DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:35 AM
MET WITH:Darlene Lindley Administrator TIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) William Vanegas made an unannounced inspection for the purposes of an annual inspection. Upon arrival LPA Vanegas was greeted by front desk receptionist, and met with Administrator (AD) Darlene Lindley and Assistant AD Lea Wine. LPA Vanegas explained reason for the inspection, began a tour of the facility, and observed the following.

This is a three storied residential care for the elderly facility with a memory care unit. Facility is operating within the conditions and limitations specified on the license. LPA Vanegas observed the facility to be clean, sanitary, and free of any debris, insects, and rodents through out the property. LPA Vanegas observed all common areas including; lobby, dinning area in assisted living unit, and dining area in memory care unit. LPA inspected resident bedrooms and observed all resident bedrooms to have required furnishings such as lamps, chairs, beds, chest drawers, enough storage space for personal belongings, and linens in good repair, meaning no strains or tears.

LPA Vanegas observed resident bathrooms to be clean and free of mildew, water faucets and toilets tested to be operational. Resident bathrooms had all required furnishings such as a shower chair, grab bars, and slip resistant matts. Water tested between 118.4 and 121.4 degrees. LPA Vanegas observed all toxins, sharps, and medications to be locked away and inaccessible to residents in care. LPA Vanegas observed a two day supply of perishable food, and a seven day supply of non-perishable food sufficient enough for all residents in care and on duty staff. LPA Vanegas also observed enough emergency water on hand for residents in care, and staff on duty.

LPA Vanegas observed the outside of the facility and there were no obstructions a long the exit routes or blocking the exit doors. There are two courtyards, one in the memory care unit, and one in the assisted living unit. They are both big enough to participate in outdoor activities upon resident request.
CONTINUED ON LIC809C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ANAHEIM VILLA
FACILITY NUMBER: 306006387
VISIT DATE: 03/11/2025
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LPA Vanegas reviewed five resident files, and five staff files all files (Staff and Resident) Consisted of all required documentation. All staff annual training is up to date, and documented. LPA Vanegas observed all fire extinguishers in common areas, and kitchen area to be fully charged and up to date. LPA Vanegas observed fire alarm testing that has been documented it is up to date, and smoke and carbon monoxide detectors tested operational.

LPA Vanegas reviewed resident medication with AD, and Medical Technician on duty, Per LPA Vanegas review medications are not being documented correctly when administered to resident's in care. LPA Vanegas observed and up to date infection control plan, and a disaster preparedness plan. Both documents were observed to have been reviewed by staff, and are fully documented.

Based on observations made during today's inspection deficiencies will be cited per tittle 22 chapter 8 division 6 of the California Code Of Regulations. An exit interview was conducted with AD Darlene Lindley and a copy of this report was left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/11/2025 01:15 PM - It Cannot Be Edited


Created By: William Vanegas On 03/11/2025 at 01:00 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: ANAHEIM VILLA
FACILITY NUMBER: 306006387

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as medications are not being documented when medication is administered which poses a potential health risk to persons in care.
POC Due Date: 03/25/2025
Plan of Correction
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AD agree's to audit medication logs, and track times that medication is being dispenced. AD agrees to send proof of correction to LPA via email by POC due date.
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:Armando J Lucero
LICENSING EVALUATOR NAME:William Vanegas
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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