331800490-3-11-2024-56-AS-MBRN-D39UE8-20240311153042

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331800490
Report Date: 03/11/2024
Date Signed: 03/11/2024 03:31:08 PM

Document Has Been Signed on 03/11/2024 03:31 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 DESCANSO SENIOR LIVING		FACILITY NUMBER:	331800490
ADMINISTRATOR:	TORRES, GABRIELA		FACILITY TYPE:	740
ADDRESS:	6683 LEANNE STREET		TELEPHONE:	(909) 332-0311
CITY:	EASTVALE	STATE: CA	ZIP CODE:	91752
CAPACITY:	6	CENSUS: 6	DATE:	03/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Sandra Hernandez		TIME COMPLETED:	03:40 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	On 03/11/2024 at 08:35 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with Staff #3 (S3) and was granted entry to the facility. At the time of the visit there were two (2) staff present, and six (6) residents present. Administrator Gabriel Torres -Thompson was contacted and informed of the visit. Facility Director Joaquin Thompson arrived during the visit. LPA Brown explained the purpose of the visit to Facility Director Joaquin Thompson. The facility is a five (5) bedroom, four (4) bathroom home with a kitchen/dining area, living room, laundry room and detached garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which four (4) can be ambulatory and two (2) non-ambulatory residents and one (1) may be bedridden resident. The facility has one (1) Hospice Waiver. The current census is six (6) residents. LPA Brown was accompanied by Staff #3 (S3) to conduct a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor passageways but observed obstruction to outdoor passageways/area. LPA Brown observed glass window in the the backyard and a fire pit not used, metal chairs and metal table in disrepair. Deficiency will be issued. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, lamps and storage space. However, LPA Brown observed insufficient lightning in Room #1 and S3 reported to LPA Brown that the light in Room #1’s not working and need to be replaced. Deficiency will be issued. Also, LPA Brown observed 2nd floor loft being utilized as bedrooms, three (3) beds observed and one (1) large sectional also being utilized as a bed. Deficiency will be issued. . *Continuation in LIC809C *

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

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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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 DESCANSO SENIOR LIVING	FACILITY NUMBER: 331800490
	VISIT DATE: 03/11/2024

NARRATIVE

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Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms.

Also, LPA Brown observed Resident #3 (R3) and Resident #5 (R5) with half bed rails Facility Director Thompson reported to LPA Brown that R3 and R5 does not have written order from the physician indicating the need for half bed rail for mobility. Deficiencies will be issued. LPA Brown measured and observed the water temperatures in the bathroom to be at 106 degrees F. The facility is equipped with operating smoke detectors, carbon monoxide alarms and charged two (2) Fire Extinguisher. Posters such as personal rights, the CCLD complaint poster, Ombudsman poster and the disaster plan were posted in a common area.

In addition, during the tour of the facility, LPA Brown observed two (2) big gallons of paint in the backyard of the facility, not locked and accessible to residents in care. Deficiency will be issued. There was a designated storage space for resident/staff files. Also, there is a designated area for the resident’s medications that's locked.

Food Service: Seven (7) days non-perishable and two (2) days perishable food supply observed at the facility.

Care & Supervision: The facility has an administrator and a facility director present in the facility. LPA Brown observed sufficient number of staff to provide care and supervision to the residents in care except for night (NOC) shift.

Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, pre-placement appraisals and care plans. LPA Brown observed no Pre-placement appraisal completed by the Licensee as required for Resident #2 (R2), Resident #3 (R3) and Resident #6 (R6) in their facility file. Deficiency will be issued. Also, LPA Brown observed Resident #3 (R3) not having an updated Physician Report, physician signature date is 07/26/2022 and per records review, R3 has dementia. Deficiency will be issued.

LPA Brown reviewed four (4) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis test result. LPA Brown observed that the files were complete. However, during the visit on 03/11/2024, LPA Brown interviewed Staff #3 (S3) and S3 reported to LPA Brown that S3's administering R3 glucose testing for R3. Deficiency will be issued.

***Continuation in LIC809C ***

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2024 03:31 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 DESCANSO SENIOR LIVING	FACILITY NUMBER: 331800490
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87628(a)

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:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Staff #3 (S3) to perform blood glucose testing to Resident #3 (R3) which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87628(a) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.

Type A

Section Cited

CCR

87705(c)(4)(A)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above by not scheduling a staff to work night (NOC) shift, awake and on duty due to having three (3) dementia residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87705(c)(4)(A) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.

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 Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2024 03:31 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 DESCANSO SENIOR LIVING	FACILITY NUMBER: 331800490
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above by having two (2) gallons of paints in the backyard, not locked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/12/2024
	Plan of Correction
1 2 3 4	Licensee removed the two (2) gallons of paint at the backyard and locked it during the visit. Licensee stated to train all staff on CCR 87705(f)(2) and submit proof of Training Log to LPA Brown at PLan of Correction (POC) due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2024 03:31 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 DESCANSO SENIOR LIVING	FACILITY NUMBER: 331800490
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(d)

Maintenance and Operation

(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above by not having a bedroom light in Room #1 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/22/2024
	Plan of Correction
1 2 3 4	Licensee stated to install a new bedroom light in Room #1 and submit proof to LPA Brown at Plan of Correction (POC) due date.

Type B

Section Cited

CCR

87307(a)(2)(B)

Personal Accommodations and Services

(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above by utilizing the 2nd floor loft as bedrooms as evidenced of three (3) beds observed and one (1) large sectional also being utilized as a bed and two (2) individuals sleeping during the visit on 03/11/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/22/2024
	Plan of Correction
1 2 3 4	Licensee stated to train all staff on CCR 87303(d) and submit proof of staff training log to LPA Brown at Plan of Correction (POC) due date. Licensee will remove the three (3) beds observed in the 2nd floor loft and submit proof to LPA Brown at POC due date

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 Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/11/2024 03:31 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 DESCANSO SENIOR LIVING	FACILITY NUMBER: 331800490
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by having Rsident #3 (R3) and Resident #5 (R5) bed rail without written order from R3 and R5 Physician indicating the need for half bed rail for mobility which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/22/2024
	Plan of Correction
1 2 3 4	Licensee removed R3 and R5 bed rail during the visit. Licensee stated to submit staff training lo6 on CCR 87608(a)(3) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by nit having an updated Physician Report for Resident #3 (R3) who has dementia which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/29/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit a copy of R3's updated Physician Report to LPA Brown at Plan of Correction (POC) due date.

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 Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: VILLA DESCANSO SENIOR LIVING	FACILITY NUMBER: 331800490
	VISIT DATE: 03/11/2024

NARRATIVE

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LPA Brown explained that S3 should assist R3 on glucose testing using "hand over hand" but not to do it for R3. S3 verbalized understanding. In addition, LPA Brown observed no staff scheduled to work on a night shift (NOC) shift. Staff #3 (S3) reported to LPA Brown that S3 sleeps when the resident sleeps at night and confirmed no staff are scheduled to work at night, awake and working at night. Deficiency will be issued.

An exit interview was conducted where this report (LIC809), LIC809D, LIC9102 TA and Appeal Rights were discussed and provided to staff Sandra Hernandez.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC809 (FAS) - (06/04)

Page: 13 of 13

Document Has Been Signed on 03/11/2024 03:31 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 DESCANSO SENIOR LIVING	FACILITY NUMBER: 331800490
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87457(c)

87457 Pre-Admission Appraisal (c) Prior to admission of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above by not completing the required Pre-Admission Appraisal for Resident #2 (R2), Resident #3 (R3) and Resident #6 (R6) which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/22/2024
	Plan of Correction
1 2 3 4	Licensee stated to submit Signed Statement of Understanding on CCR 87457(c) to LPA Brown at Plan of Correction (POC) due date.

Type B

Section Cited

CCR

87307(d)(6)

87307 Personal Accomodation and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above not having the backyard free of obstruction as LPA Brown observed glass window, old fire pit, in disrepair metal chairs and table in the backyard which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/22/2024
	Plan of Correction
1 2 3 4	Licensee stated to remove the glass window, old fire pit, in disrepair metal chairs and table in the backyard to LPA Brown at Plan of Correction (POC) date.

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 Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2024

LIC809 (FAS) - (06/04)

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