370804416-3-17-2025-08-AS-CLOZ-DEURNU-20250317131056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370804416
Report Date: 03/17/2025
Date Signed: 03/17/2025 01:11:14 PM

Document Has Been Signed on 03/17/2025 01:11 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	VILLA VICTORIA CARE HOME		FACILITY NUMBER:	370804416
ADMINISTRATOR/ DIRECTOR:	LABRADOR, VICTORIA N.		FACILITY TYPE:	740
ADDRESS:	1312 LEAF TERRACE		TELEPHONE:	(619) 266-2356
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92114
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	03/17/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:54 AM
MET WITH:	Fe Oca, Caregiver and Victoria Labrador, Licensee		TIME VISIT/ INSPECTION COMPLETED:	01:15 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) Carmen Lopez conducted an unannounced required Annual Inspection. The facility file was reviewed prior to the visit. LPA Lopez identified herself, was granted entry by caregiver Fe Oca. LPA discussed the purpose of the visit with caregiver Oca and licensee Victoria Labrador later arrived and joined the visit. According to the facility’s license, there may be a maximum of six (6) residents all of whom may be non-ambulatory in at any given time at the facility site. During today’s inspection, the facility’s current census is 5 residents living at the facility. There were 5 residents present at the facility site during the inspection. LPA, accompanied by caregiver Oca, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary and in good repair. Pathways were free of obstruction and slip hazards. Resident’s bedrooms contained the required furnishings. Doors, windows, toilets, and showers were in working order. Extra linens and hygiene supplies were present. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and activities. The facility’s ambient internal temperature was comfortable and compliant, at 70 degrees Fahrenheit (F). Hot water temperature at taps accessible to residents were also compliant: sink in restroom #1 delivered hot water at 117 degrees F; sink in restroom #2 delivered hot water at 114.4 degrees F; and sink in restroom in #3 delivered hot water at 116.8 degrees F. The temperature at taps not accessible to residents and is only used by staff read as follows: kitchen sink delivered hot water at 126 degrees F. The facility did not have a caution sign posted. There was at least 2 days of perishable food, and at least 7 days non-perishable food present. Cooking, dining equipment and utensils were present, and all safely stored. There were no toxic chemicals or poisons accessible to residents. There were chemicals under the kitchen sink and sharps that were in an unlocked drawer, but there was a door barrier that prevented resident access to the area. [CONTINUED ON LIC 809-C]

Robyn Clark	TELEPHONE: (619) 767-2312
Carmen Lopez	TELEPHONE: (619) 767-2301
	DATE: 03/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VILLA VICTORIA CARE HOME	FACILITY NUMBER: 370804416
	VISIT DATE: 03/17/2025

NARRATIVE

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[CONTINUED FROM LIC 809]

Medications were properly labeled, as required, and stored in a locked cabinet. One resident’s medications were placed in a labeled container but according to staff and licensee that specific medication container, with medications, is not used by the facility. The medication container is given and used solely by the resident when they leave the facility for a few days, and the medication is taken with them. LPA inspected the medication cabinet. The facility-maintained medication logs which LPA reviewed.

No pools or bodies of water on the premises. Per caregiver Oca, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all working. Fire extinguisher(s) were present (01) and serviced within the last 12 months. First aid kit was complete and readily accessible.

LPA interviewed staff and resident, and reviewed staff and resident records. During today’s visit there were 5 residents on the facility premise. LPA interviews did not raise any licensing concerns. The files which LPA reviewed contained required documents. Confidential records were stored in a locked area. Required licensing postings were observed in a visible area of the facility.

There was a deficiency observed and cited during today's annual inspection, and may be found on the LIC809-D page of this report. There were also technical advisories and technical violations provided to the facility at the conclusion of the visit.

LPA informed Licensee Labrador of the new Department updates effective January 1, 2025, for the senior care regulations. LPA provided licensee with the Department flyer and demonstrated how and where to find the regulation updates. LPA informed Licensee Labroador the facility's Plan of Operations will need to be updated.

An exit interview was conducted with licensee Victoria Labrador to whom a copy of this report along with the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the documents were received.

Licensee Labrador submitted a current Designation of Administrative Responsibility LIC 308 and Personnel Report LIC 500, to the licensing office January 2025. LPA requested am updated copy of their Emergency Disaster Plan LIC 610-E, within 10 business days. Forms are available at www.ccld.ca.gov.

SUPERVISOR'S NAME: Robyn Clark	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/17/2025 01:11 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VILLA VICTORIA CARE HOME	FACILITY NUMBER: 370804416
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87463(a)

Reappraisals

(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 [R1, R2, and R3] out of 5 resident appraisals were not updated which posed a potential personal rights risk to persons in care.
	POC Due Date: 04/07/2025
	Plan of Correction
1 2 3 4	Licensee agreed to submit R1, R2, and R3's updated appraisals to the Department and addressed to LPA by POC due date, 04/07/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Robyn Clark	TELEPHONE: (619) 767-2312
Carmen Lopez	TELEPHONE: (619) 767-2301
	DATE: 03/17/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2025

LIC809 (FAS) - (06/04)

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