370804416-2-14-2024-08-AS-CLOZ-D2G3A3-20240214170404

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 370804416
Report Date: 02/14/2024
Date Signed: 02/14/2024 05:05:55 PM

Document Has Been Signed on 02/14/2024 05:05 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	VILLA VICTORIA CARE HOME		FACILITY NUMBER:	370804416
ADMINISTRATOR:	LABRADOR, VICTORIA N.		FACILITY TYPE:	740
ADDRESS:	1312 LEAF TERRACE		TELEPHONE:	(619) 266-2356
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92114
CAPACITY:	6	CENSUS: 5	DATE:	02/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Victoria Labrador, Licensee		TIME COMPLETED:	04:00 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 RosaFe Dela Cruz. LPA discussed the purpose of the visit with Licensee Victoria Labrador. 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 Dela Cruz, 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, as well as some Personal Protective Equipment (PPE). The facility needed additional PPE supplies. 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 clients were also compliant: kitchen sink delivered hot water at 119.8 degrees F; sink in restroom #1 delivered hot water at 102.7 degrees F; sink in restroom #2 delivered hot water at 119.1 degrees F. 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/poisons accessible to residents. Medications were properly labeled, as required, and stored in a locked cabinet. LPA inspected the medication room and found that medications were properly labeled and stored. The facility maintained medication logs which LPA reviewed. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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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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: 02/14/2024

NARRATIVE

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[CONTINUED FROM LIC 809]

No pools or bodies of water on the facility premises. Per licensee Victoria Labrador, 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(s) were complete and readily accessible.

LPA interviewed staff and residents, 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 were deficiencies observed and cited during today's annual inspection and may be reviewed on the last page of this report.

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.

LPA requested Licensee Labrador to submit a current Designation of Administrative Responsibility LIC 308, Emergency Disaster Plan LIC 610-E, and Residential Infection Control Plan LIC 9282 (6/23), to the licensing office within 10 business days. Forms are available at www.ccld.ca.gov. A current Personnel Report LIC 500 form was provided to the LPA during the visit.

SUPERVISOR'S NAME: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/14/2024 05:05 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: 02/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(d)

Personnel Records

(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements. 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 1 out of 1 certifications of Licensee's license was not obtained which posed a potential personal rights risk to persons in care.
	POC Due Date: 03/07/2024
	Plan of Correction
1 2 3 4	Licensee will call the Department certification unit to obtain their recertification records and submit either their certificate or have their name added to the pending list, by POC due date, 03/07/2024.

Type B

Section Cited

CCR

87705(c)(5)

Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. 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 2 out of 2 Physician's Reports for dementia residents were not updated which posed a potential health, risk to persons in care.
	POC Due Date: 03/07/2024
	Plan of Correction
1 2 3 4	Licensee will be scheduling the PCP's appointments for residents and have their Physician's Reports updated.

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: Jennifer Lott	TELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC809 (FAS) - (06/04)

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