331881248-3-11-2024-56-AS-MMAE-D39S8A-20240311133850

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881248
Report Date: 03/11/2024
Date Signed: 03/11/2024 01:39:01 PM

Document Has Been Signed on 03/11/2024 01:39 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	WESTFIELD VILLA GARDENS		FACILITY NUMBER:	331881248
ADMINISTRATOR:	MARIA JASMIN DOLORES		FACILITY TYPE:	740
ADDRESS:	3863 WEST RAMSEY ST		TELEPHONE:	(951) 849-7521
CITY:	BANNING	STATE: CA	ZIP CODE:	92220
CAPACITY:	50	CENSUS: 33	DATE:	03/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	Maria Jasmin Dolores, Administrator		TIME COMPLETED:	01:40 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	Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Maria Jasmin Dolores, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with (3) floor levels. The facility has a license capacity of (50) non-ambulatory residents, a current census of (33) residents in care, and a hospice waiver for (30) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor activity area is sufficient for resident activities and is enclosed with self-latching gates. The facility is maintained at a comfortable temperature. Resident bathrooms audited were equipped with grab rails and non-skid mats. Resident bathroom showers, toilets, and hand washing areas were operating properly and the hot water temperature measured 117 degrees F. Resident bedrooms audited had beds, chairs, nightstands, and sufficient lighting; However, a deficiency is being cited for not maintaining bedroom #19 clean and free of odors. Facility staff stated that they have scheduled an appointment for tomorrow (3/12/24) with an outside service company to have the carpet in bedroom #19 cleaned and sanitized. The facility has operating carbon monoxide alarms, laundry equipment, telephone service, and each floor level has an operating signal system. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, resident activities, evacuation exit plan and emergency telephone numbers. Sharps, disinfectants, and cleaning solutions were kept locked and inaccessible to residents in care. Care & Supervision: Facility has 24-hour, 7 days a week care staff.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WESTFIELD VILLA GARDENS	FACILITY NUMBER: 331881248
	VISIT DATE: 03/11/2024

NARRATIVE

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Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. The facility has posted in the kitchen a list of residents with modified diets. The facility has menus posted in the dining area.
Record Review: (6) staff files audited had criminal record clearances, health screening, employment applications, and current first aid/CPR training. (6) resident files audited had admissions agreements, physician's reports, assessments, theft and loss policy, and personal rights statements. The facility’s Administrator’s certification and liability insurance are current. The facility has an infection control and an emergency disaster plan on file. The facility’s last fire drill was conducted on 1/10/24.
Medical Related Services: (6) Resident’s medications audited were labeled and centrally stored in a locked cabinet. The facility had first aid kits and first aid manuals.

Based on observations and record review, a deficiency is being cited per Title 22, of The California Code of Regulations.

An exit interview was conducted where this report and a plan of correction was discussed with Administrator Dolores. A copy of this report was provided with Appeal Rights to the Administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
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 01:39 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WESTFIELD VILLA GARDENS	FACILITY NUMBER: 331881248
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87625(b)(3)

Managed incontinence 87625 (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above by not maintaining bedroom #19 clean and free of odors; 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	The Licensee/Administrator shall submit to the Licensing Agency receipts of carpet cleaning by 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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
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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