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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881418
Report Date: 06/14/2023
Date Signed: 06/14/2023 02:55:43 PM


Document Has Been Signed on 06/14/2023 02:55 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
RIVERSIDE, CA 92507



FACILITY NAME:VILLA BERNARDOFACILITY NUMBER:
371881418
ADMINISTRATOR:DERAFERA, TESSFACILITY TYPE:
740
ADDRESS:2960 BERNARDO AVETELEPHONE:
(858) 925-8858
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:10CENSUS: 9DATE:
06/14/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Applicant Zayden ChenTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Janira Arreola, conducted an announced visit for the purpose of conducting the prelicensing inspection. LPA met with applicant Zayden Chen and administrator Teresa Derafera for the visit. The applicant is seeking a change of ownership for a residential care facility for the elderly with a capacity for (10) residents, ages 60 and up.

LPA conducted a walk through of the interior and exterior of the facility. The home is a (10) bedroom and (3) bathroom, one story home. The fire clearance conducted on 4/18/2023 by Escondido Fire Department was approved the home for (10) non-ambulatory residents. The resident bedrooms were observed to had the appropriate linens, furniture such as bed, dresser, closet space, light, night stand and chair. The home has extra linens and bath towel in a hallway closet. First aid kit was locked in kept locked with medications. The facility kitchen has enough pots and pans, cooking utensils, plates and cups for (10) Residents. The applicant will send the LPA proof of purchase of non-perishable foods by 6/15/2023. LPA observed the bathrooms in the facility to have hand hygiene supplies, and personal care items were kept in locked closet. The laundry room was observed be functional, and the facility possesses cleaning supplies to conduct regular cleaning of the facility which were locked in laundry room. The smoke alarms and carbon monoxide detectors were found in working condition. The dining room was observed and the outdoor area is free of hazards. LPA observed the home has activities for clients to engage in, and observed residents in their rooms and in living area playing BINGO. The hot water temperature was recorded in the facility restroom at 109.7F and the land line was observed to be operational (858-925-8858). No bodies of water or firearms are being kept in the facility. Kitchen knifes will be kept locked in a kitchen drawer.

LPA observed the facilities MARS sheets for resident, Administrator's current certificate, and staff files which were kept locked in facility hallway.

An exit interview was conducted were this report was reviewed and provided to the applicant, Zayden Chen and Administrator Teresa Derafera.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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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