<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881169
Report Date: 10/13/2023
Date Signed: 10/13/2023 03:05:26 PM

Document Has Been Signed on 10/13/2023 03:05 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:ANDREW VILLA LLCFACILITY NUMBER:
361881169
ADMINISTRATOR:GHAREB, RAWANFACILITY TYPE:
735
ADDRESS:27051 VILLA AVETELEPHONE:
(909) 280-3783
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 6CENSUS: 2DATE:
10/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Rawan GharebTIME COMPLETED:
03:07 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Anna Bueno made an announced visit to the facility to conduct a required annual inspection. LPA identified herself to Licensee Rawan Ghareb who was advised of the purpose of the visit.

The facility is currently licensed as an Adult Residential Facility, vendored by the Inland Regional Center. The facility has capacity of four ambulatory clients. One client and one staff were present during this visit.

LPA Bueno and Licensee Ghareb toured the interior and exterior of the facility. The facility has no bodies of water. There is a shaded patio area for clients. LPA and Licensee observed that side gate was unlocked and free of obstruction. The facility had a working telephone for client use. The facility fire extinguishers were last inspected on 08/1/2023. LPA and Licensee tested bedroom smoke alarms and one carbon monoxide detector and found units to be in working order. A locked centralized cabinet is used for medications, client and staff files, and facility records. Sharps, toxins, and cleaning agents are kept locked and secured.

The following were observed of the physical plant:
Client Bedrooms and Bathroom: LPA and Licensee observed all bedrooms to have the required bedding and furniture, such as, clean mattresses/linen, sufficient storage space, chairs, and lighting. The facility had a supply of additional linens and towels. LPA and Licensee observed bathrooms were kept in sanitary conditions and provisions for hygiene items are available.
Kitchen and Dining Areas: LPA and Licensee inspected the kitchen and found dishes, glasses, and utensils were in good condition and stored in a safe manner. LPA and DSP inspected food provisions and found at least a 2-day supply of perishable food and 7-day supply of non-perishable food.
Common (living/activity) areas: LPA and Licensee observed adequate seating in the common areas. Each client room had a supply of personal enrichment activities. Calendar of activities were observed.

The following records were inspected:
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2023
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: ANDREW VILLA LLC
FACILITY NUMBER: 361881169
VISIT DATE: 10/13/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Client Records: LPA inspected two of two client files and found both have the required documentation, including but not limited to, an admissions agreement and current Individual Program Plan (IPP).
Staff Records: LPA reviewed one staff file with current administrator certificate and CPR.
Centralized Medication: LPA reviewed two client medications. LPA and Licensee observed all scheduled medications were administered as prescribed.
LPA reviewed training and disaster drill logs. Licensee completed an updated LIC 610D, emergency disaster plan.

No deficiencies were issued during today's visit. An exit interview was conducted where this report was provided to Rawan Ghareb at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2