336405651-7-21-2023-18-AS-JROO-CTXSD7-20230721134639

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336405651
Report Date: 07/21/2023
Date Signed: 07/21/2023 01:46:46 PM

Document Has Been Signed on 07/21/2023 01:46 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 ANNE		FACILITY NUMBER:	336405651
ADMINISTRATOR:	FE MAESTRADO		FACILITY TYPE:	740
ADDRESS:	3011 NOVA SCOTIA		TELEPHONE:	(951) 784-1066
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92506
CAPACITY:	6	CENSUS: 6	DATE:	07/21/2023
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Licensee Fe Maestrado		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	On 7/21/2023, 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, Rosalinda Manlolo who was informed of the purpose of visit. Licensee Fe Maestrado arrived shortly after. The facility is approved for 6 non-ambulatory residents, of which one (1) may be bedridden. During the visit, there was six (6) residents and (2) staff present. LPA toured the facility’s interior and exterior with Licensee Maestrado. During the visit, LPA observed the following: Kitchen: LPA toured the kitchen and observed kitchen to be clean. Food is stored in a safe and healthful manner. Utensils and dishware are sufficient for the approved capacity. LPA observed food supply met the requirement for a two-day supply of perishable food and seven-day supply of non-perishable food items. Knives/sharp instruments are secured in a locked kitchen cabinet. Fire extinguisher is charged and mounted on kitchen wall. Dining and Living room: LPA toured the dining and living/family room area. LPA observed area to be clean and furniture in good condition. LPA observed residents sitting in the living room watching television. Fireplace had appropriate barrier. Hallway: LPA observed hallway to be clean with no pathway obstruction. Carbon monoxide & smoke detectors were tested and functioning properly. Cleaning solutions are secured in hallway cabinet.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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 ANNE	FACILITY NUMBER: 336405651
	VISIT DATE: 07/21/2023

NARRATIVE

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Centrally Stored Medications: LPA observed a first aid kit with required components. Medications were secured in a cabinet near the kitchen. LPA reviewed physical medications for two residents as well as Medication Destruction Record and no discrepancies were discovered.

Bedrooms: Resident bedrooms were each furnished with a bed, chair, closet, clothing storage and lighting.

Bathrooms: Bathrooms have a working toilet, wash basin, and were equipped with a grab bar in the shower. The hot water temperature measured at 116-degrees Fahrenheit. The facility has clean towels, blankets, and linen, available in different colors for the residents in care.

Laundry/Garage: LPA observed laundry room and garage to be clean. Washing machine and dryer are in good repair. An additional refrigerator and freezer are stored in the garage.

Records: Staff present have a criminal record clearance on file and are associated to the facility. Staff training is up to date.

Yard/Outside Area: Covered patio seating is available for residents. A wood wall secured the entire backyard. All outdoor pathways were free of obstructions. No bodies of water were observed. There were no firearms or ammunition observed at the facility, and LPA was informed the facility will not store firearms or ammunition on the premises.

LPA did not observe any deficiencies. An exit interview was conducted, and a copy of this report was reviewed and provided to Licensee Maestrado.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Janette Romero	TELEPHONE: (951) 248-0350
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC809 (FAS) - (06/04)

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