342700134-5-2-2024-59-AS-DAWL-D4VQXA-20240502123314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700134
Report Date: 05/02/2024
Date Signed: 05/02/2024 12:54:55 PM

Document Has Been Signed on 05/02/2024 12:54 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME:	VILLA WESTLAKE		FACILITY NUMBER:	342700134
ADMINISTRATOR:	HUANG, JIAN L		FACILITY TYPE:	740
ADDRESS:	490 HAWKCREST CIRCLE		TELEPHONE:	(916) 813-8018
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95835
CAPACITY:	6	CENSUS: 6	DATE:	05/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:31 AM
MET WITH:	Alicia Portela, Administrator Pending		TIME COMPLETED:	01:00 PM

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On May 2, 2024 at 10:30am Licensing Program Analyst (LPA) De Anna Williams-Lyons arrived unannounced to conduct an Annual Required Inspection of the facility to ensure compliance with Title 22 regulations. LPA Lyons met with Alicia the Administrator who assisted LPA in today’s inspection. The current census is 6. The facilities Administrator’s Certificate, Emergency Disaster Plan, Resident’s Rights and Facility Sketch was available for viewing. The room temperature was 73 degrees F which is within range.

LPA and Alicia did not completed the inspection tool questionnaire due to computer issues.

LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, and kitchen. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. Hot water temperatures were taken and measured at 112 degrees F. There’s appropriate lighting throughout the facility.

First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards.

LPA inspected the Living room, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be enough and in good repair. Resident bedrooms and bathrooms were toured. Bedrooms had all the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer were present and operating properly. Toxic substances, laundry and cleaning supplies are inaccessible.

To continue see 809-C...

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VILLA WESTLAKE	FACILITY NUMBER: 342700134
	VISIT DATE: 05/02/2024

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There’s a centralized storage area for resident’s medication. Medication cabinet was locked. The facility Medication Administration Record was reviewed as well as the dispensing log and was complete and current.

Resident’s files were reviewed. LPA reviewed 2 resident files and 2 staff files. All Documents were present and up to date. Staff records reviewed indicated current First Aid & CPR certificates. Facility is conducting staff training as required.

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations were observed.

An exit interview was conducted, and a copy of this report was given to Alicia.

The administrator shall submit updated copies of the LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610E the Emergency Disaster Plan, and copy of your current Liability Insurance to update the facility file in our Regional Office. Administrator shall submit the listed documents to Licensing no later than June 2, 2024.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons	TELEPHONE: (916) 212-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024

LIC809 (FAS) - (06/04)

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