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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881418
Report Date: 06/17/2024
Date Signed: 06/17/2024 11:12:12 AM


Document Has Been Signed on 06/17/2024 11:12 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Gerald Malda, CaregiverTIME COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Javina George, made an unannounced visit for the purpose of conducting a 1 year required visit/annual inspection. LPA met with Caregiver Gerald Madla where LPA explained the purpose of the visit. The facility is licensed for a capacity for (10) residents, ages 60 and up, with an approved hospice waiver for (10). There are currently (4) residents receiving hospice services. On 4/18/2023 by Escondido Fire Department approved the home for (10) non-ambulatory residents. At the time of LPAs visit there were (3) staff and (9) residents present. All staff present have obtained proper fingerprint clearance, however Staff #1 is not associated to the facility, a $500 penalty is being assessed, andDeficiency cited.

During today's visit LPA conducted a walk through of the interior and exterior of the facility. The facility is a single story home with (10) bedrooms and (3) bathrooms. The facility was observed to be clean, clutter and odor free. The exits and passageways are free from obstruction. The resident bedrooms were observed to had have the required furniture ( bed, chest of drawers, adequate lighting, chair).

There are no pools or bodies of water, or known guns or ammunition on the premises. The facility smoke and carbon monoxide detectors were tested and were found to be operable. LPA conducted a review of facility records and observed for the facility to have no record of emergency disaster drills being conducted on a quarterly basis. Deficiency cited.

The facility was observed to have a 2 day supply of perishable and a 7 day supply of non-perishable food items. The medications are stored in a locked cabinet inside the hallway, the facility utilizes Medication Administration Records (MAR) to assist with tracking the administering the resident's medications. The facility is to submit a copy of current liability insurance to the regional office. The annual fees for the facility have not been paid as of today's date and are due on or before 6/21/24. LPA will provide the PIN so that the fees can be paid electronically.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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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Document Has Been Signed on 06/17/2024 11:12 AM - 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: VILLA BERNARDO
FACILITY NUMBER: 371881418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 times as there has not been a drill conducted within the last quarter, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2024
Plan of Correction
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The licensee agrees to conduct an emergency disaster drill, and document the conducted drill. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/17/2024 11:12 AM - 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: VILLA BERNARDO
FACILITY NUMBER: 371881418

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.17(c)(1)(A)
Licensing
(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 1 times as S1 is not associated to the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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The licensee agrees to associate S1 to the facility. Proof of POC (copy of Guardian roster, showing S1 is associated) is to be submitted to the department by 5pm on the due date indicated.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLA BERNARDO
FACILITY NUMBER: 371881418
VISIT DATE: 06/17/2024
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Based on today's inspection a citation(s) will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8).

An exit interview was conducted and a copy of this report, 809D, LIC9098-Proof of Corrections form, LIC421BGand appeal rights were provided to Gerald Madla, Caregiver.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 217-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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