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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336401178
Report Date: 05/06/2022
Date Signed: 05/06/2022 01:38:15 PM


Document Has Been Signed on 05/06/2022 01:38 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
RIVERSIDE, CA 92507



FACILITY NAME:VILLA SAN JUAN BOARD & CARE FOR ELDERLYFACILITY NUMBER:
336401178
ADMINISTRATOR:SAN JUAN, TEODORA L.FACILITY TYPE:
740
ADDRESS:798 DE PASSE WAYTELEPHONE:
(951) 765-9202
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY:6CENSUS: 5DATE:
05/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Teodora San Juan - Licensee/AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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On this date, Licensing Program Analyst (LPA) Crystal Colvin made an unannounced visit to the facility to investigate a complaint #118-AS-20220503120310. During today's inspection, LPA Colvin observed the following deficiencies, which was reviewed with Licensee/Administrator Teodora San Juan:
  • P&I Funds: LPA Colvin learned through interviews and record review that the facility is assisting a resident (R1) with management of their P&I funds, despite the facility not having a Surety Bond. Deficiency cited. Additionally, R1's funds are being held in the Licensee/Administrator's private bank account. Deficiency cited.

  • Medical Records: LPA Colvin observed through review of R1's facility file that R1 is diagnosed with Dementia. Additionally, R1's most recent Physician's Report is dated 1/7/21. Title 22 Regulations states that all residents with Dementia must be examined by a physician annually. Deficiency cited. In relation to the complaint #18-AS-20220503120310, R1's fall (and reported physical aggression towards staff) was not documented in R1's file, despite this being a new behavior and dramatic change in R1. Deficiency cited. LPA Colvin inquired as to if R1's doctor was made aware of this incident (and subsequent bruise on R1's arm), and LPA Colvin was informed by the Licensee/Administrator that they have not spoken to R1's doctor. Deficiency cited.

  • Personal Rights - During LPA Colvin's interview with Licensee/Administrator Teodora, the following statement was made by the Licensee/Administrator in relation to a conversation they had with R1 after the incident mentioned above: "I told her that I can call 911 and 51/50 her and that she will not like it. I told her not to hit anyone or I will do that". This statement can be viewed as a threat or form of intimidation in order to have R1 behave in the way that the Licensee/Administrator wants them to. Deficiency cited.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


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
RIVERSIDE, CA 92507
FACILITY NAME: VILLA SAN JUAN BOARD & CARE FOR ELDERLY
FACILITY NUMBER: 336401178
VISIT DATE: 05/06/2022
NARRATIVE
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Due to the deficiencies cited today as well as the substantiated complaint (#18-AS-20220503120310), LPA Colvin is recommending an Informal Meeting to be held between the Licensee, LPA Colvin, and LPM Joel Esquivel. LPA Colvin will contact the Licensee next week in order to coordinate a date and time for the meeting.

Due to observations made by LPA Colvin, the facility was cited and deficiencies are noted on the LIC809D page(s). LPA Colvin conducted an exit interview with Administrator/Licensee Teodora San Juan, and a copy of this report, LIC809Ds, and appeal rights was provided.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/06/2022 01:38 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
RIVERSIDE, CA 92507


FACILITY NAME: VILLA SAN JUAN BOARD & CARE FOR ELDERLY
FACILITY NUMBER: 336401178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2022
Section Cited

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Personal Rights of Residents..: (a) Residents ...shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met by:
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Based on interviews, the Licensee did not comply with the above regulation with one resident. LPA Colvin cofirmed that R1's physician was not notiied of R1's reported new aggressive behavior, or R1's bruise from the incident. This is an immediate personal rights violation of R1.
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Type A
05/09/2022
Section Cited

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Additional Personal Rights of Residents...:(a) In addition to the rights listed...residents...shall have all of the following personal rights: (8) To be free from...intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by:
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Based on interviews, the Licensee did not comply with the above regulation with one resident. LPA Colvin learned that the Licensee threatened/intimidated R1 with a statement about calling 911 & having R1 51/50'd if they hit staff in the future. This is an immediate personal rights violation of R1.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 05/06/2022 01:38 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
RIVERSIDE, CA 92507


FACILITY NAME: VILLA SAN JUAN BOARD & CARE FOR ELDERLY
FACILITY NUMBER: 336401178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2022
Section Cited

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Bonding: (a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal. This requirement was not met by:
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Based on interview and record review, the Licensee did not comply with the above regulation with one resident. LPA Colvin learned that the facility is handling money for R1 without a surety bond. This is a potential personal rights violation of R1.
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Type B
05/13/2022
Section Cited

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Safeguards for Resident Cash...and Valuables: (e) Cash resources and valuables of residents which are handled by the licensee for safekeeping shall not be commingled with or used as the facility funds or petty cash, and shall be separate, intact and free from any liability.... This requirement was not met by:
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Based on interview, the Licensee did not comply with the above regulation with one resident. LPA Colvin learned that R1's funds are being stored in the Licensee's personal bank account. This is a potential personal rights violation of R1.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 05/06/2022 01:38 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
RIVERSIDE, CA 92507


FACILITY NAME: VILLA SAN JUAN BOARD & CARE FOR ELDERLY
FACILITY NUMBER: 336401178

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2022
Section Cited

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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...and a reappraisal done at least annually... This requirement was not met as evidenced by:
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Based on record review, the Licensee did not comply with the above regulation with one resident. LPA Colvin observed that R1 is diagnosed with Dementia, and R1's most recent physicia's report is dated 1/7/21. This is a potential health risk to R1.
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Type B
05/13/2022
Section Cited

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Observation of the Resident : The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning...When changes...are observed, the licensee shall ensure that such changes are documented... This requirement was not met by:
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Based on record review and interview, the Licensee did not comply with the above regulation with one resident. LPA Colvin confirmed that an incident of reported new aggressive behavior of R1 was not documented. This is a potential health and safety risk for R1.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5