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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880736
Report Date: 10/25/2022
Date Signed: 10/25/2022 12:20:35 PM

Document Has Been Signed on 10/25/2022 12:20 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, 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: 2DATE:
10/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Sherry Drayton McCall, LicenseeTIME COMPLETED:
12:28 PM
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On 10/25/2022 at 10:23 a.m.,Licensing Program Analyst (LPA) Rayshaun Nickolas made 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 arrived at the facility, rang the doorbell and knocked on the door several times but no one was present at the facility. At 10:24 a.m., LPA phone Licensee Sherry Drayton McCall about the attempted annual inspection and the Drayton McCall stated he/she will arrive at the facility in 15 minutes. At 10:43 a.m., Drayton McCall arrived at the facility and met with LPA. LPA was screened for COVID-19 symptoms and asked to sign-in upon arrival. Drayton McCall confirmed that there are currently no cases/exposures of COVID-19 within the facility.

During the inspection, LPA Nickolas conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures and other health and safety concerns. LPA observed appropriate postings throughout the facility, including hand-washing etiquette, face coverings, and COVID-19 symptoms postings. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA observed that the Licensee wearing a mask during the visit. 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 (CCLD) guidelines for COVID-19 testing, isolating/quarantining 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. LPA reviewed resident records and interviewed Licensee.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: VILLA'S ADULT RESIDENTIAL HOME
FACILITY NUMBER: 361880736
VISIT DATE: 10/25/2022
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LPA observed no apparent health and safety concerns at the time of visit.

No deficiencies cited during today's visit. An exit interview was conducted where this report was discussed, and a copy of this report was provided to Drayton McCall at the conclusion of the inspection.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC809 (FAS) - (06/04)
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