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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336401178
Report Date: 05/18/2022
Date Signed: 05/18/2022 02:07:43 PM


Document Has Been Signed on 05/18/2022 02:07 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: 4DATE:
05/18/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Teodora San Juan - Licensee/AdministratorTIME COMPLETED:
02:15 PM
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An Informal Meeting was conducted today in order to discuss recent concerns and facility's operation. Persons present at today’s meeting were: Licensing Program Manager (LPM) Joel Esquivel, Licensing Program Analyst (LPA) Crystal Colvin, and Licensee/Administrator Teodora San Juan. Below are the topics that were addressed during the Informal Meeting:
  • Substantiated Complaint #18-AS-20220503120310

  • Resident P&I Funds

  • Resident Records & Documentation

  • Recently Cited Deficiencies (Case Management Visit 5/6/22)


During this meeting it was requested for the Licensee to create a ledger of all P&I money handled by the facility for the resident (R1) including all detailed expenditures, deposits, and un-cashed checks. P&I ledger to be provided to LPA Colvin by June 1, 2022. Additionally, it was requested to have the Licensee provide Licensing with an updated Program Plan regarding handling aggressive behaviors of residents, including training to be provided to staff. Updated Program Plan to be submitted to LPA Colvin by June 1, 2022. Lastly, Licensee to ensure R1 is seen by a physician and have an updated Physicians Report by June 1, 2022, a copy of which shall be provided by the Licensee to LPA Colvin.

LPM Joel Esquivel and LPA Crystal Colvin offered Licensee/Administrator Teodora San Juan the Technical Support Program (TSP) Assistance. The Licensee was receptive to the referral for TSP. LPA Colvin to submit a referral for the facility. An exit interview was conducted and a copy of this report was provided to Licensee/Administrator Teodora San Juan.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 05/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2022
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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