335530032-8-3-2022-56-AS-ABUO-CGXQ54-20220803115120

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 335530032
Report Date: 08/03/2022
Date Signed: 08/03/2022 11:51:28 AM

Document Has Been Signed on 08/03/2022 11:51 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 ANZA		FACILITY NUMBER:	335530032
ADMINISTRATOR:	ESPINAL, KENNY		FACILITY TYPE:	740
ADDRESS:	5881 EL PALOMINO DRIVE		TELEPHONE:	(951) 683-3333
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY:	197	CENSUS: 92	DATE:	08/03/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:44 AM
MET WITH:	Moises Bercovich and Kenny Espinal		TIME COMPLETED:	11:55 AM

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) Anna Bueno conducted a pre-licensing inspection . LPA identified herself to licensee Moises Bercovich and executive director (ED) Kenny Espinal who was informed of the purpose of today's visit. The facility is currently licensed as a Residential Care Facility for the Elderly (RCFE) and the the pending application is for a change of ownership. The facility has been granted fire clearance by Riverside Fire Department on 7/12/2022 for 197 non-ambulatory residents, 15 of whom may be bedridden. LPA, ED, and Licensee toured the interior and exterior areas of the facility. ED confirmed that fire alarms and carbon monoxide detectors were serviced during fire clearance inspection. The following were inspected: LPA, Licensee, and ED observed required licensing postings including the ombudsman's poster, CCLD complaint poster, residents and council rights, and the facility's emergency/disaster phone numbers by the front desk and along hallways. There is a locked centralized area for medications, first aid supplies, and client files. LPA, ED, and Licensee inspected the facility kitchen and found it to be clean with sufficient food storage space. There is at least a 7 day supply of non-perishable foods, 2 day supply of perishable foods, and emergency food supplies. LPA observed storage areas for cleaning supplies and toxins were inaccessible to residents. LPA inspected an available resident unit and found the room to have sufficient storage space and lighting. Bathroom appliances were operational and were equipped with grab bars and textured flooring. LPA observed the bathing are with textured floor and ED confirmed that this is standard for all units. *************CONTINUED ON LIC 809C*************

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

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	FACILITY NUMBER: 335530032
	VISIT DATE: 08/03/2022

NARRATIVE

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LPA, Licensee, and ED inspected common rooms. There were several activity areas and a dining area for residents. The outdoor space has shaded seating area for residents. The building appears to be in good repair and is equipped with functioning utilities. Overall, the facility appears to meeting operational compliance for residents in care and the surrounding remain clean and safe.

COMP III was waived due to Licensee is currently managing several other facilities in other counties. The pre-licensing inspection is complete and this facility has no deficiencies. Licensee has satisfied all requirements in accordance with Title 22, California Code of Regulations.

An exit interview was conducted where this report was discussed with and a copy was provided Licensee and ED at the conclusion of the inspection.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022

LIC809 (FAS) - (06/04)

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