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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800471
Report Date: 02/21/2023
Date Signed: 02/21/2023 09:11:34 AM


Document Has Been Signed on 02/21/2023 09:11 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, 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:
02/21/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Executive Director Ashley WillettTIME COMPLETED:
09:15 AM
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Licensing Program Analyst (LPA) Melody Brown met with Executive Director Ashley Willett, a designee of Chief Executive Officer Betty Dominici at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 02/21/2023 at 08:00 AM to initiate a Case Management - Deficiency. LPA Brown explained the purpose of the requested Office Visit.

LPA Brown reviewed Resident #1 (R1) facility documents and LPA Brown observed that per R1’s LIC602A Physician Report, R1’s Physician reported that R1 needs assistance in Oxygen Administration. Staff interviews indicated that they are providing Resident #1 (R1) assistance on oxygen administration. Also, staffs’ interviews revealed that they are not skilled professional, but they are providing assistance on oxygen administration to R1. On 02/07/2023, LPA Brown contacted Staff #1 (S1) and S1 reported to LPA Brown that caregivers and medical technicians (MedTechs) were assisting R1 on R1’s oxygen administration as the facility don’t have a nurse onsite. Residents’ interviews revealed that caregivers and MedTechs staffs are assisting residents on their oxygen administration,

LPA Brown explained to Administrator Willett that it is the facility's responsibility to ensure that R1’s provided assistance on oxygen administration based on R1’s LIC602A Physician Report and that the facility must ensure that assistance on oxygen administration is provided by an appropriately skilled professional. LPA Brown will issue a citation for the facility not ensuring that assistance on oxygen administration for R1 is provided by an appropriately skilled professional 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 Executive Director Ashley Willett.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/21/2023 09:11 AM - 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: 02/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2023
Section Cited

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87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee...(2) Ensuring that oxygen administration is provided by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidenced by:
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Licensee will submit Signed Statement of Understanding on CCR 87618(b)(2) 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 Oxygen Administration assistance was provided 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: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
LIC809 (FAS) - (06/04)
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