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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800471
Report Date: 12/29/2022
Date Signed: 12/29/2022 04:05:39 PM


Document Has Been Signed on 12/29/2022 04:05 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:VILLA DE ANZAFACILITY NUMBER:
331800471
ADMINISTRATOR:KENNY ESPINALFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 685-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:0CENSUS: 0DATE:
12/29/2022
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ms. Betty Dominici TIME COMPLETED:
11:30 AM
NARRATIVE
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On 12/29/2022, Licensing Program Analyst (LPA) Melody Brown contacted Ms. Betty Dominici via zoom meeting at 10:00 AM to initiate a Case Management - Deficiency. LPA Brown explained the purpose of the requested Zoom Meeting. The investigation consisted of observation, interviews and a review of pertinent documentation.

LPA Brown interviewed Resident 1 (R1) and R1 indicated staff were performing the blood glucose meter for R1 as staff were providing assistance as R1's legally blind. LPA Brown interviewed staffs and staffs reported that they performed blood glucose meter testing for R1 and also read R1's blood glucose reading as they were told by previous Business Office Director (S10) who's in charge of the facility that time due to R1 being legally blind. Staffs interviews revealed that they are aware of the "hand over hand process/procedure" but staffs reported that when they started working at the facility, they were trained and were told to perform blood glucose meter reading for R1, not just reading the blood glucose meter, not indicating to use the hand over hand procedure/process due to R1 being legally blind but to perform the blood glucose testing for R1. LPA Brown contacted previous Executive Director (S1) to inquire if S1 had knowledge of MedTech staffs performing blood glucose testing for R1 and S1 denied knowledge of such staff practice until the incident reported involving R1 last 10/17/2021. Moreover, S1 said that the facility had an Immediate In-service Training to all Medical Technician (MedTech) Staffs that day upon discovery of the wrong practice to inform them that injections like blood glucose meter are administered/performed by appropriately skilled professional to residents requiring assistance like R1 and Medtechs are not allowed to perform blood glucose meter or injections to residents in care. S1 added that last 10/17/2021, facility management was informed and S1 requested to arrange skilled professional to go to the facility to perform R1's blood glucose testing and provide assistance.

LPA Brown reviewed R1's Physician Report and Admission Agreement indicating R1 needs assistance on administering own prescription medications, R1 needs assistance on administering own injections, needs assistance to perform own glucose testing and Physician reported assistance needed to R1 being legally blind.

*** Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: VILLA DE ANZA
FACILITY NUMBER: 331800471
VISIT DATE: 12/29/2022
NARRATIVE
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LPA Brown explained to Ms. Dominici that upon admission of R1 last 03/29/2021 who has diabetes, R1 must be able to perform own blood glucose testing or with staff assistance using hand over hand process, and R1 must be able to administer own medication including medication administered orally or through injection or with staff assistance using the hand over hand process, or if R1's condition changed and R1's unable to do it on its own with staff assistance through the process of hand over hand, it has to be performed or administered by an appropriately skilled professional. LPA Brown added that it is the facility's responsibility to ensure that if R1's unable to perform own blood glucose testing with staff assistance using the hand over hand process that R1's blood glucose testing must be performed by an appropriately skilled professional and must not be delayed as R1's Physician Report indicated R1 needs assistance and R1's Physician also reported R1 being legally blind as blood glucose testing must be performed first, and a requirement before assisting R1 on administering R1's insulin medication and must not be delayed.

LPA Brown will issue a citation for the facility not ensuring that R1 blood glucose testing was performed/administered by an appropriately skilled professional as R1 requires assistance per R1's LIC602A Physician Report and this pose immediate health, safety and personal rights risks to resident in care.

An exit interview was conducted where this report (LIC809), LIC80D, and Appeal Rights were discussed and provided to Ms. Betty Dominici.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 12/29/2022 04:05 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: VILLA DE ANZA
FACILITY NUMBER: 331800471

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2022
Section Cited

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87628 Diabetes (a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by:

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Licensee will submit Signed Statement of Understanding on CCR 87628(a) to LPA Brown by POC due date.


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Based on interview and records review, the Licensee did not comply with the section cited above by not ensuring that R1 blood glucose testing was performed/administered by an appropriately skilled professional as R1 requires assistance which pose immediate health, safety and personal rights risk to resident in care.
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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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2022
LIC809 (FAS) - (06/04)
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