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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347002829
Report Date: 12/21/2023
Date Signed: 12/21/2023 03:47:56 PM


Document Has Been Signed on 12/21/2023 03:47 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 LINDAFACILITY NUMBER:
347002829
ADMINISTRATOR:BACHIS, GABRIELFACILITY TYPE:
740
ADDRESS:6501 LINDA WAYTELEPHONE:
(916) 217-2056
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY:6CENSUS: DATE:
12/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Gabriel BachisTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cassie Yang and Cheyenne Ratajczak arrived unannounced at the facility to conduct a required 1-year annual inspection utilizing the full CARE tool. LPAs met with Administrator, Gabriel Bachis, and explained the purpose of the visit.

LPAs and Administrator discussed Administrator's current status regarding his Administrator Certificate. LPA Yang provided Admin Cert Unit's email address and general phone number to Administrator.

A tour was conducted to ensure the health and safety of residents in care. No immediate health, safety or personal rights violations were observed.

File review conducted and found annual training missing. LPAs and Administrator further discussed reporting requirements regarding submitting an incident report (LIC 624) to Licensing in a timely manner in cases of a death and/or incidents regarding resident's welfare. Additionally, it was discussed for fire extinguishers to be serviced annually.

LPA Yang provided Administrator a copy of Health and Safety Code 1569.625 Staff training; legislative findings; contents regarding annual training. Additionally, LPA provided a copy of California Code Regulation 87211 Reporting Requirement.

During today's visit, Inspection tool completed, please see LIC 809-D.

Exit interview conducted and a copy of report and appeal rights provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
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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Document Has Been Signed on 12/21/2023 03:47 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: VILLA LINDA
FACILITY NUMBER: 347002829

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
ยง1569.625 Staff training; legislative findings; contents
(b) (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
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Based on file review and interview, the licensee did not comply with the section cited above in 2 out of 3 personnel files were observed to have no annual trianings, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/21/2024
Plan of Correction
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Licensee will submit a statement of understanding that all staff needs annual 20 hours of training. Submit statement to LPA Yang by 01/21/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Cassie YangTELEPHONE: (916) 201-1928
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023
LIC809 (FAS) - (06/04)
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