331881251-1-5-2024-56-AS-MMAE-CZ7T7D-20240105132835

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881251
Report Date: 01/05/2024
Date Signed: 01/05/2024 01:29:05 PM

Document Has Been Signed on 01/05/2024 01:29 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:	WESTHILLS VILLA GARDENS		FACILITY NUMBER:	331881251
ADMINISTRATOR:	MARIA JASMIN DOLORES		FACILITY TYPE:	740
ADDRESS:	5466 WEST WILSON ST.		TELEPHONE:	(951) 849-7521
CITY:	BANNING	STATE: CA	ZIP CODE:	92220
CAPACITY:	30	CENSUS: 21	DATE:	01/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Maria Jasmin Dolores, Administrator		TIME COMPLETED:	01:35 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 a license capacity of (30) and a current census of (21) residents in care. The facility has 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: Indoor and outdoor passageways are free of obstruction. The facility has no bodies of water accessible to residents in care. The facility has sufficient indoor space for resident activities. Outdoor activity space is fenced and sufficient for resident activities. The facility has sufficient lighting and is maintained at a comfortable temperature. Resident’s bathroom equipment were in operation condition. The hot water temperature in residents' bathrooms measured 105 to 118 degrees F; however, the facility did not ensure infection control practices were maintained by having uncovered trash containers with tissue in residents bathrooms. Resident’s bedrooms have sufficient lighting, operating signal system, and furniture in good repair. The facility has operating carbon monoxide alarms and telephone service. The facility has sufficient linen, blankets, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, resident's personal rights and emergency telephone numbers.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

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: WESTHILLS VILLA GARDENS	FACILITY NUMBER: 331881251
	VISIT DATE: 01/05/2024

NARRATIVE

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Food Service: Facility has sufficient non-perishable and perishable food supply for residents in care. The refrigerator and freezer are operating in a healthful manner. Pesticides and other cleaning solutions were kept locked and stored away from food areas.

Care & Supervision: Facility has 24-hour support staff.

Record Review: Staff files reviewed were observed to be complete and included criminal record clearances or exemptions through the Department. Resident files reviewed were observed to be complete. Administrator’s certification expires on 7/15/2024. The facility did not have a current emergency drill conducted with staff on file.

Medical Related Services: All medication is centrally stored and kept in a locked cabinet. The facility has a complete first aid kits with a first aid manual.

Deficiencies are being cited per Title 22, Division 6 of The California Code of Regulations.

An exit interview was conducted where reports LIC809/LIC809-C/LIC809-D were discussed. Copies of the licensing reports with appeal rights were provided 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: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/05/2024 01:29 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: WESTHILLS VILLA GARDENS	FACILITY NUMBER: 331881251
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87470(a)(2)(D)

Infection Control Requirements

(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products. These activities shall be completed, at a minimum, as follows: (D) Facility items that cannot be disinfected shall be discarded immediately in an appropriate waste receptacle with a tight-fitting cover or otherwise made inaccessible to human contact or transmission. 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 having uncovered trash containers with tissue in residents bathrooms; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the Licensing Agency proof of covered trash containers by POC due date

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA file review, the licensee did not comply with the section cited above by the facility did not have a current emergency drill conducted with staff on file.which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/25/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator shall submit to the Licensing Agency proof of drill conducted by 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: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024

LIC809 (FAS) - (06/04)

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