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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880736
Report Date: 11/23/2021
Date Signed: 11/23/2021 10:42:44 AM

Document Has Been Signed on 11/23/2021 10:42 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VILLA'S ADULT RESIDENTIAL HOMEFACILITY NUMBER:
361880736
ADMINISTRATOR:DRAYTON MCCALL, SHERRYFACILITY TYPE:
735
ADDRESS:11262 VILLA STTELEPHONE:
(760) 523-1607
CITY:ADELANTOSTATE: CAZIP CODE:
92301
CAPACITY: 3CENSUS: 1DATE:
11/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Sherry Drayton McCallTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Stephanie Williams conducted an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA Williams identified herself to Administrator, Sherry Drayton McCall, and also discussed the purpose of the visit with McCall. LPA Williams was asked to sign-in and provide a temperature reading upon arrival. McCall confirmed that the facility currently does not have any COVID-19 positive cases.

During the inspection, LPA Williams interviewed the Administrator pertaining to the facility's infection control measures and inspected the facility for regulatory compliance. LPA Williams observed appropriate postings in the facility, including COVID-19 symptoms postings and visitation policies, which were in accordance with the Department's guidelines. The Administrator confirmed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA Williams observed that the facility staff were wearing face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the facility's infection control measures. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation of residents, and properly caring for residents with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and emergency personnel in the event the resident presents any COVID-19 symptoms.

Based on interviews and observations made during today’s inspection, one technical violation was issued for reporting requirements. Interviews with the Administrator revealed that the facility's COVID-19 Mitigation Plan (LIC 808) has not been received by the Department in a timely manner. An exit interview was conducted where this report was discussed and a copy of this report was provided to McCall at the conclusion of the inspection.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Stephanie Williams
LICENSING EVALUATOR SIGNATURE: DATE: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/23/2021
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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