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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 01:39:26 PM


Document Has Been Signed on 05/06/2022 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
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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Teodora San Juan - Licensee/AdministratorTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with Licensee/Administrator Teodora San Juan and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Licensee/Administrator Teodora San Juan, who LPA Colvin found to be successfully incorporating the several aspects of the facility's Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns), which was located in the front of the facility. LPA Colvin observed the facility to not have an adequate supply of face N95 masks or isolation gowns. Licensee/Administrator Teodora San Juan informed LPA Colvin that there is more next door at the Licensee's sister facility, however, there needs to be adequate amount at each location. LPA Colvin will be issuing the facility a Technical Advisory Note instead of a deficiency, as the facility has enough in supply for current daily use. LPA Colvin went over the various recommended training for facility staff with Licensee/Administrator Theodora San Juan in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE.

LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Licensee/Administrator Teodora San Juan stated that they have not. LPA Colvin will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results.
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)
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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
RIVERSIDE, CA 92507
FACILITY NAME: VILLA SAN JUAN BOARD & CARE FOR ELDERLY
FACILITY NUMBER: 336401178
VISIT DATE: 05/06/2022
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LPA Colvin will be providing Licensee with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

LPA Colvin additionally observed that while the facility is utilizing a sign-in log for visitors, it does not include temperature screening, and LPA Colvin's temperature was not taken upon entry to the facility. LPA Colvin will be issuing a Technical Assistance Advisory Note for this item. Lastly, LPA Colvin observed a "No Visitors" sign at the front door of the facility. LPA Colvin instructed Licensee/Administrator to remove the sign, as visitation has not been limited to exclude friends and family for over one year.

An exit interview was conducted with Licensee/Administrator Teodora San Juan and a copy of this report and LIC9102 TA Advisory Notes were 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)
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