331800471-3-16-2022-56-AS-MBRN-CCKRJ7-20220316130327

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800471
Report Date: 03/16/2022
Date Signed: 03/16/2022 01:03:45 PM

Document Has Been Signed on 03/16/2022 01:03 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 ANZA ASSISTED LIVING		FACILITY NUMBER:	331800471
ADMINISTRATOR:	KENNY ESPINAL		FACILITY TYPE:	740
ADDRESS:	5881 EL PALOMINO DRIVE		TELEPHONE:	(951) 685-3333
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY:	144	CENSUS: 68	DATE:	03/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Executive Director Kenny Espinal		TIME COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Melody Brown arrived at the facility 03/16/2022 at 09:40 AM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with Executive Director Kenny Espinal and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed: Infection Control: LPA Brown went over COVID-19 best practices for infection control and prevention with Executive Director Kenny Espinal. The facility has a Mitigation Plan which was submitted last 01/12/2022. LPA Brown observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and emergency contact information for the residents. LPA Brown toured the facility's resident bedrooms and bathrooms and observed that both resident bathrooms have paper towels and hand soap. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply, which is stored in the storage office. LPA Brown observed the facility to have a 30-day supply of gloves, masks, sanitizer, face shields and isolation gowns. LPA Brown went over the various recommended training for facility staff with Executive Director Kenny Espinal in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE. LPA Brown inquired as to if staff have been fit tested for N95 masks, and Executive Director Kenny Espinal informed LPA Brown that all staff have been fit tested. LPA Brown informed Executive Director Espinal that N95 masks only needs to be worn when a resident is COVID-19 positive or under observation while awaiting test results. Additionally, most residents and staff have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. ** continuation on LIC809C *

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

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 ASSISTED LIVING	FACILITY NUMBER: 331800471
	VISIT DATE: 03/16/2022

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LPA Brown inquired about if the facility is still conducting COVID-19 surveillance testing of their staff members. Executive Director Kenny Espinal informed LPA Brown that staff have continued to be tested every week for COVID-19. In addition to going over the facility's policy for testing staff and residents for COVID-19, LPA Brown also inquired about if the facility is still screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Executive Director Kenny Espinal confirmed that staff continues to monitor residents’ symptoms, and that staff are screened for COVID-19 symptoms prior to entering the facility. LPA Brown additionally observed an electronic temperature log kept by the facility where all temperatures for staff, residents and visitors are taken and recorded daily. Moreover, LPA Brown confirmed that the facility is verifying their visitor’s vaccination status as well.

During the visit, LPA Brown observed no smoke detectors on south side of the facility - first, second and third floor and only three (3) smoke detectors found in the north side, first floor of the facility and none on the second and third floor and Executive Director Espinal requested Maintenance and Housekeeping Director Manuel Ledesma to put or install carbon monoxide detectors on north side of the facility, all floors and second and third floor of the south side of the facility during the visit. LPA Brown will be issuing a technical violation today due to no smoke detectors observed on the identified area and floors of the facility and LPA Brown observed that smoke detectors were installed today during the visit.

Throughout today's inspection, LPA Brown observed all staff wearing masks. LPA Brown additionally observed residents not wearing a mask, and LPA Brown advised Executive Director Kenny Espinal to encourage the residents to wear masks when in common areas indoors, though they cannot be forced.

An exit interview was conducted with Executive Director Kenny Espinal and a copy of this report (LIC809) and LIC9102 AN Technical Violation were discussed and provided.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/16/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022

LIC809 (FAS) - (06/04)

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