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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 335530032
Report Date: 09/09/2022
Date Signed: 09/09/2022 05:58:35 PM


Document Has Been Signed on 09/09/2022 05:58 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 ANZAFACILITY NUMBER:
335530032
ADMINISTRATOR:ESPINAL, KENNYFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 683-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:197CENSUS: 91DATE:
09/09/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Katherine TrevinoTIME COMPLETED:
06:06 PM
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to conduct a Health and Safety check of the clients in care at the facility. LPA Gardner met with Administrator Katherine Trevino and explained the reason for the visit.

The Health and Safety check included overall observation of the facility inside, and outside, including food supply, physical plant, and the clients in care.

During today’s visit, LPA Gardner was informed that the central AC has been broken since 9/1/22. The central AC unit is broken in room 245, on portions the 2nd floor hallway, and portions 3rd floor hallway. LPA was given documentation showing that the Administrator purchased five (5) portable AC units and three (3) box fans on 9/3/22. There is a portable AC unit being used temporality in room 245. There are no fans or portable units being used in the hallways. Trevino stated that the licensee has made four (4) attempts to call the AC company “Total Air” that the facility is contracted to work with. LPA inquired if the licensee had tried contacting additional AC companies and was informed that they had not attempted to find another company.

LPA toured the resident bedrooms throughout the facility and found that most of the resident’s bedrooms have wall AC’s. There are some resident bedrooms with central air units. During interviews with residents, LPA was informed that the residents were uncomfortable with the temperature in their bedrooms prior to the Administrator purchasing portable AC units. There were two (2) residents that stated that at one point their bedrooms were between 88 degrees Fahrenheit and 90 degrees Fahrenheit prior to using portable AC units. The temperature in the residents bedrooms with the portable units are currently between 61 degrees Fahrenheit and 81 degrees Fahrenheit.

Based on the observations made during today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations. Further deficiencies will be issued on another date.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
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: 09/09/2022
NARRATIVE
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An exit interview was conducted, and this report was discussed and provided to Administrator Katherine Trevino,
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/09/2022 05:58 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 DE ANZA
FACILITY NUMBER: 335530032

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/10/2022
Section Cited
CCR
87468.1(a)(2)

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87468.1. Personal Rights of Residents in All Facilities.(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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The licensee has agreed to provide CCL with a work contract to replace or repair the central air conditioning units that are broken. The licensee has agreed to check each resident bedroom in the building to inspect the wall AC units. The licensee has agreed to purchase new wall AC units for the bedrooms that are not a comfortable temperature.
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Based on interview and observation, the licensee did not comply with the section cited above by having broken air conditioning units in the common areas which poses an immediate health, safety or personal rights risk to persons in care.
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The licensee has agreed to read regulation 87468.1 entirely and send LPA self certify letter that the regulation was read and understood. This POC is due by 9/10/2022.

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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 ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
LIC809 (FAS) - (06/04)
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