336402944-7-24-2024-18-AS-SMAZ-D7GUFS-20240724153315

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336402944
Report Date: 07/24/2024
Date Signed: 07/24/2024 03:33:22 PM

Document Has Been Signed on 07/24/2024 03:33 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 ASC, 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: 5	DATE:	07/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:12 PM
MET WITH:	Teodora San Juan, Administrator		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	Licensing Program Analyst (LPA), Stephanie Martinez, made an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPA was greeted and allowed to enter the facility to conduct the inspection. On today’s visit the LPA met with Administrator, Teodora San Juan. She was notified of the purpose for the visit. PHYSICAL PLANT: Residents appear to be protected against immediate hazards. The Licensee has an approved waiver granted for a locked perimeter gate. No pool or body of water was observed on the property. According to the Administrator, there are no weapons kept on the property. A comfortable temperature was being maintained in the home. There was sufficient lighting in resident bedrooms to ensure the comfort and safety of residents. Resident bedrooms were fully furnished with required furniture. Toilets, hand washing and bathing facilities were kept safe, sanitary, and in operating condition. Additional equipment for physically handicapped residents is available. The smoke and carbon monoxide alarms were tested and found to be in operating condition. The interior and exterior areas of the home were observed to be clean and safe. FOOD SERVICE: Food supply of nonperishable and perishable foods was sufficient. Sufficient supplies for resident's dinning use were observed to be available. RECORD REVIEW: Staff files did not have required training, such as annual medication training or training on Dementia, Postural Supports, Restricted Health Conditions or Hospice. Citations will be issued. First Aid and CPR training was observed on file for care staff. Staff present had the required criminal record clearances. The LPA observed proof of liability insurance and the Emergency Disaster Plan in place. Hospice Care Plans are on file for residents in care. Admission Agreements, Medical Assessment (Physician's Report), Assessments, and Service Plans were observed on file for residents in care. Administrator San Juan has an active Administrator's certificate, which expires on 12/25/2025. The facility currently has 2 residents in care

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

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 ASC, 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: 07/24/2024

NARRATIVE

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receiving hospice services, which is within their Hospice Waiver limit. The Licensee is not operating the facility in compliance with the waiver for locked perimeter gates that was approved on 03/07/2014. According to Administrator San Juan, there are no written consent forms for any resident in care acknowledging that the facility has exterior perimeter gates that are locked, and that the resident voluntarily consents to admission.

MEDICATION: Medication storage areas were inspected. Medications were labeled and maintained in compliance with label instructions and State and Federal law. Medications were observed to be safe, organized, and inaccessible to residents in care.

This report was reviewed with Administrator San Jaun and a copy was provided, along with the LIC 811, LIC 9098 and instructions on appeal rights.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/24/2024 03:33 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 ASC, 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: 07/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two (2) out of two (2) staff members (S2 and S3) who did not have the above required training. According to Administrator, no current training has been completed. This poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 08/24/2024
	Plan of Correction
1 2 3 4	Administrator stated training certificates for S2 and S3 will be submitted to the Department by the POC due date.

Type B

Section Cited

CCR

1569.69(b)

Employees assisting residents with self-administration of medication; training requirements: (b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two (2) out of two (2) staff members (S2 and S3) who have not completed the above required training. According to Administrator, no current medication training has been completed for S2 or S3. This poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 08/24/2024
	Plan of Correction
1 2 3 4	Administrator stated training certificates for S2 and S3 will be submitted to the Department by the 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: Rikesha Stamps	TELEPHONE: (951) -212-0616
LICENSING EVALUATOR NAME: Stephanie Martinez	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024

LIC809 (FAS) - (06/04)

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