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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004466
Report Date: 04/23/2024
Date Signed: 04/23/2024 11:00:09 AM


Document Has Been Signed on 04/23/2024 11:00 AM - 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:TRAJAN VILLA CARE HOMEFACILITY NUMBER:
347004466
ADMINISTRATOR:FLORICA SOTEAFACILITY TYPE:
740
ADDRESS:6201 TRAJAN DRIVETELEPHONE:
(916) 358-6907
CITY:ORANGEVALESTATE: CAZIP CODE:
95662
CAPACITY:6CENSUS: 3DATE:
04/23/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Co-administrator- Eugen Georgescu TIME COMPLETED:
11:10 AM
NARRATIVE
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Licensing Program Analyst (LPA) Talwinder Bains arrived at the facility unannounced on 04/23/24 to do case management visit. LPA met with Co-administrator, Eugen Georgescu and explained the purpose of the visit.

During complaint investigation (59-AS-20240319092550), LPA learned that resident, R1 was sent to hospital /ER due to change in condition on 01/30/24 which should have been reported to Department as required per Title 22 Regulations. Based on the records reviewed, it has been determined that the facility did not report this incident for resident R1, regarding R1s hospital/ER visit for 01/30/24. Through records review and staff interviews, it is determined that although facility may have generated SIR (LIC624), the facility failed to submit SIR (LIC624) to the Department as required by regulations. Based on this information, citation has been issued per Title 22 Regulations as indicated on 809-D.

Exit interview conducted. Appeal Rights and copy of this report has been provided.

SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
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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Document Has Been Signed on 04/23/2024 11:00 AM - 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: TRAJAN VILLA CARE HOME
FACILITY NUMBER: 347004466

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2024
Section Cited
CCR
87211(a)(1)(D)

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87211- Reporting Requirements-
(a) Each licensee shall furnish to the licensing agency such reports as the Department [...]: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident [...] (D) Any incident which threatens the welfare, safety or health of any resident [...]This requirement was not met as evidenced by:
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Licensee to review section 87211 Reporting Requirements and send a letter of understanding to Community Care Licensing. Additionally, licensee to ensure incident reports are filled out and faxed to CCL with confirmation. All POC documents are due by 05/05/24.
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Based on interviews and records review, the facility did not comply with the section cited above by not reporting incident which threatened the welfare of R1. This poses a potential health, safety, and/or personal rights risk to residents in care.
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Talwinder BainsTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
LIC809 (FAS) - (06/04)
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