336402944-7-15-2022-18-AS-CCON-CGCU5S-20220715151714

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336402944
Report Date: 07/15/2022
Date Signed: 07/15/2022 03:17:33 PM

Document Has Been Signed on 07/15/2022 03:17 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 THE ELDERLY #2		FACILITY NUMBER:	336402944
ADMINISTRATOR:	TEODORA L. SAN JUAN		FACILITY TYPE:	740
ADDRESS:	786 DE PASSE WAY		TELEPHONE:	(951) 765-9202
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	6	CENSUS: 6	DATE:	07/15/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Teodora San Juan - Licensee/Administrator		TIME COMPLETED:	02:00 PM

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) 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 LPA Colvin observed the facility have an adequate supply. LPA Colvin went over the various recommended training for facility staff with Licensee/Administrator Teodora 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 confirmed that staff have been fit tested. LPA Colvin inquired about if the facility is screening their residents daily for COVID-19 symptoms, which includes checking their temperature. Licensee/Administrator Teodora San Juan confirmed that residents are being screened daily. LPA Colvin observed a sign-in sheet at the front door of the facility, and confirmed that visitors and staff are being screened for symptoms prior to entering the facility, as LPA Colvin was also screened during entry. Other Issues: During LPA Colvin's inspection, two additional items outside of Infection Control were observed which need to be addressed.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

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 THE ELDERLY #2	FACILITY NUMBER: 336402944
	VISIT DATE: 07/15/2022

NARRATIVE

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Resident Personal Storage - LPA Colvin observed that one of the private resident bedrooms has a closet used by the resident which is also being used to store isolation gowns. This is a violation of the resident's (R1) rights, as their bedroom had to be entered in order for facility staff to get to the gowns. Deficiency cited.

Capacity Limitations & Furniture - LPA Colvin observed that all four of the facility bedrooms contain two beds, while the facility has a maximum capacity of six. This is of concern as the facility could be using the beds to house additional residents beyond their capacity, or they are using private resident bedrooms (two private rooms) as additional storage for excess facility furniture/supplies. Deficiency cited. Administrator informed LPA Colvin the residents use the beds for their items.

Staff Sleeping in Common Area - Upon LPA Colvin's entry to the facility, LPA Colvin observed a Day Bed in the living room which was made up with sheets and pillows positioned at one side of the bed. LPA Colvin inquired with staff (S1) as to who sleeps on the bed, and staff admitted to sleeping on the bed. LPA Colvin inquired as to if the staff member who sleeps on the bed lives at the facility, and the staff member agreed. LPA Colvin observed that there is no other staff sleeping quarters. Deficiency cited.

Staff Sleeping in Garage - Due to the excessive number of beds in the facility as well as staff sleeping in the living room, LPA Colvin inspected the garage and observed another bed made up with linen in the garage. LPA Colvin asked staff who sleeps on that bed, and LPA Colvin was informed that the Administrator sometimes sleeps on the bed. The facility's Fire Clearance does not permit for the garage to be used as living quarters. Deficiency cited.

Flies/Insects - LPA Colvin observed a single fly in the dining room, as well as a fly strip hanging in the kitchen. LPA Colvin is not citing a deficiency and instead issuing Technical Advisory Note as the fly was no longer present when the Licensee arrived, and the staff are taking some measures to control the pests.

Licensing Fees - LPA Colvin observed that the facility's annual Licensing Fees for 2022 are due. The facility's anniversary date is July 2022, so the fees are not considered late as of yet, which is why LPA Colvin is issuing Technical Advisory Note instead of a deficiency during today's inspection.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/15/2022 03:17 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 THE ELDERLY #2	FACILITY NUMBER: 336402944
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87308(c)

Resident and Support Services: (c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in1 of 4 resident bedrooms, which poses a potential personal rights risk to persons in care. LPA Colvin observed that one of the private resident bedrooms has isolation gowns for the facility being stored in the resident's closet.
	POC Due Date: 07/22/2022
	Plan of Correction
1 2 3 4	Licensee agrees to remove facility property (isolation gowns) from resident's priavte personal storage. Licensee may self-certify to LPA Colvin once complete.

Type B

Section Cited

CCR

87307(a)

Personal Accommodations and Services: (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 4 of 4 resident bedrooms, which poses/posed a potential personal rights risk to persons in care. LPA Colvin observed that the facility has 6 residents but 8 beds (between the 4 resident bedrooms). The licensed capacity for the facility is 6, meaning that the facility has no reason to have more than 6 resident beds. Priavte rooms are also storing additional beds, which cannot be used by additional residents.
	POC Due Date: 07/29/2022
	Plan of Correction
1 2 3 4	Licensee agrees to remove the additional beds from the resident bedrooms. Licensee to provide LPA Colvin with photographic proof of bedrooms with beds removed, as well as photographic proof of where the beds were moved to (if they remain on facility grounds). Alternatively, Licensee may obtain signed statements from residents/family stating desire for extra bed to remain in the room and for what purpose. Plan of Correction due by 7/29/22.

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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/15/2022 03:17 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 THE ELDERLY #2	FACILITY NUMBER: 336402944
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/15/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in 1 room of the facility (living room), which poses a potential personal rights risk to persons in care. LPA Colvin observed a Day Bed in the living room of the facility, which was made up with sheets and pillows at one end of the bed. LPA Colvin inquired with staff who sleeps on the bed, and S1 confirmed that they sleep on the bed. The living room is being used by staff as a bedroom.
	POC Due Date: 07/22/2022
	Plan of Correction
1 2 3 4	Licensee agrees to remove the Day Bed from the Living room, or cease staff using the day bed to sleep on. Licensee to submit self-certification to LPA Colvin that correction has been made, along with statement regarding what the resolution was (where staff are now sleeping or if no staff sleep on facility grounds). Plan of Correction due by 7/22/22.

Type B

Section Cited

CCR

87203

Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 living quarters/room (garage), which poses a potential safety risk to persons in care. LPA Colvin observed there to be a bed made up with linen in the garage. LPA Colvin inquired with staff as to who sleeps in the garage. Staff informed LPA Colvin that the Administrator sometimes sleeps in the garage. The Fire Marshall has not cleared the garage for sleeping quarters.
	POC Due Date: 07/29/2022
	Plan of Correction
1 2 3 4	Licensee agrees to either remove the bed with linens from the garage and cease having anyone sleep in the garage, or obtain an updated Fire Clearance from the Fire Marshall which states that the garage may be used as living quarters. Licensee to provide either updated Fire Clearance or Photos with Statement of Understanding regarding garage not to be used as sleeping quarters. Plan of Correction due by 7/29/22.

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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

LIC809 (FAS) - (06/04)

Page: 4 of 7

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 THE ELDERLY #2	FACILITY NUMBER: 336402944
	VISIT DATE: 07/15/2022

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 26 27 28 29 30 31 32	An exit interview was conducted with Licensee/Administrator Teodora San Juan and a copy of this report, LIC9102 TA Advisory Notes, and LIC809D was provided

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2022

LIC809 (FAS) - (06/04)

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