336402944-7-30-2023-18-AS-JROO-CU8UGS-20230730153446

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336402944
Report Date: 07/30/2023
Date Signed: 07/30/2023 03:34:57 PM

Document Has Been Signed on 07/30/2023 03:34 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
RIVERSIDE AC/SC, 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:	07/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Licensee Teodora San Juan		TIME COMPLETED:	03:45 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	On 7/30/2023, at 12:30 p.m., Licensing Program Analyst (LPA) Janette Romero arrived unannounced at the facility to conduct an annual required visit. LPA was greeted and granted entry by Caregiver Maricel Francia who was informed of the purpose of visit. Licensee Teodora San Juan arrived during LPA's tour of the facility's interior and exterior. The facility is approved for 6 non-ambulatory residents of which one (1) may be bedridden. The facility has a hospice waiver for two (2). During the visit, there was four (6) residents and (2) staff present. LPA observed the following: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition. LPA observed residents in their rooms watching television and sleeping. Hallway was clean with no pathway obstruction. Facility has a fire alarm system, carbon monoxide and smoke detectors. Facility has a first aid kit with required components. Medications were secured in a locked hallway cabinet. LPA reviewed physical medications for Resident #1 as well as Medication Destruction Record, no discrepancies discovered. Bathroom has a working toilet, wash basin, and were equipped with a grab bar in the shower. The hot water temperature measured at 105-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the residents in care. Emergency food supplies, water, additional hygiene supplies and incontinent supplies are stored in the garage. Shaded seating area is available for the residents to sit and relax. All outdoor pathways were free of obstructions. No bodies of water were observed. Continued on LIC809-C..

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2023

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
RIVERSIDE AC/SC, 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: 07/30/2023

NARRATIVE

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Upon arrival to the facility, LPA observed the refrigerator had a white plastic chain with a master lock. Caregiver Francia stated that long ago, the facility housed a resident that had dementia, and would open the refrigerator, take the eggs out, throw them on the floor or attempt to eat them, raw. Caregiver Francia stated that facility staff would lock the refrigerator using the white plastic chain and master lock observed by LPA, to avoid the resident from consuming raw eggs or throwing the eggs on the floor. Licensee San Juan stated to LPA that the refrigerator was locked for the purpose of storing resident medication that required refrigeration. LPA did not observe any resident medication in the refrigerator and informed Licensee San Juan that the refrigerator storing resident food cannot be locked and residents need to have access to food. LPA also informed Licensee that LPA observed a small refrigerator in front of Room #3 with a built-in keyed lock, which Caregiver Francia confirmed is used to store resident medication that requires refrigeration. LPA asked Caregiver Francia to remove plastic chain and lock from refrigerator.

During the tour of the kitchen, LPA observed the cabinet storing canned goods and non-perishables had a hasp and staple door latch. LPA did not observe a lock. Licensee asked LPA if they could lock the pantry to prevent canned goods and non-perishables from falling during earthquakes. LPA reiterated to Licensee that residents need to have access to food and the facility cannot lock the refrigerator/pantry storing food items for the residents in care. LPA asked Licensee to remove hasp and staple door latch.

While inspecting the food supply available for the residents at the facility, LPA found food with an expiration tag noted food to be used by 2016. LPA assessed that food that is to be used by 2016 would not be of good quality if served to the residents in 2023. Licensee disposed of all expired food items.

LPA also observed unsecured knives and scissors stored in a kitchen cabinet along with unsecured cleaning solutions stored under the kitchen sink.

Based on the aforementioned, LPA issued deficiencies faulting the facility. An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee San Juan along with an LIC809-D and Appeals Rights.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/30/2023 03:34 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
RIVERSIDE AC/SC, 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: 07/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. 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 due to LPA observing unsecured cleaning solutions during tour of the kitchen, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2023
	Plan of Correction
1 2 3 4	Licensee agreed to provide staff training regarding storing disinfectants and cleaning solutions and making them inaccessible to residents in care. Proof of correction to be submitted to CCLD by POC due date.

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. 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 due to LPA finding food with an expiration tag noted to be used by 2016, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2023
	Plan of Correction
1 2 3 4	Licensee agreed to impliment a policy wherein food is checked regularly for expiration dates to ensure that no expired food is accessible to residents. Staff removed expired food items at the time of the visit. Proof of new facility policy to be submitted to CCLD by close of business on POC due date.

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: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 07/30/2023 03:34 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
RIVERSIDE AC/SC, 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: 07/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). 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 due to LPA observing unsecured knives and scissors during tour of the kitchen, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2023
	Plan of Correction
1 2 3 4	Licensee agreed to provide staff training regarding storing of items that if accessible would pose a danger to residents with dementia. Proof of correction to be submitted to CCLD by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 07/30/2023 03:34 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
RIVERSIDE AC/SC, 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: 07/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(3)

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: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. 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 due to LPA observing white plastic chain with master lock on refrigerator and facility staff admitting to previously locking refrigerator storing resident food, which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2023
	Plan of Correction
1 2 3 4	Licensee agreed to provide staff training to ensure facility staff maintain refrigerator and pantry storing resident food unlocked at all times. Proof of correction to be submitted to CCLD by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2023

LIC809 (FAS) - (06/04)

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