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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881418
Report Date: 07/18/2024
Date Signed: 07/18/2024 11:49:17 AM


Document Has Been Signed on 07/18/2024 11:49 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:
07/18/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:House Manager, Odette DeraferaTIME COMPLETED:
11:55 AM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola, conducted an unannounced visit to the facility for an unrelated matter and documented deficiencies observed. LPA met with House Manager, Odette Derafera, who was informed of the purpose of the visit. During the visit, LPA conducted an interview and walk through of the facility. A health and safety check was conducted on the facility residents, the following violations were observed:

During the walk through LPA observed (2) video monitors with audio with live feeds showing residents in their rooms. The use of video surveillance in residents rooms are not permitted, and the use of video with audio capabilities is not permitted. LPA also reviewed the current staff scheduled for the week, and identified staff present during the time of the visit. (1) staff was not associated to the facility.

The deficiencies were cited and a plans of correction was created with the house manager. The criminal record clearance has a civil penalty of $100 per day per person for the maximum of (5) days. The facility is being cited a total of ($500) in civil penalties.

An exit interview was conducted with the house manager, where this report, LIC811, deficiency pages, civil penalty pages, and appeal rights were reviewed and provided to them.

SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
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 3


Document Has Been Signed on 07/18/2024 11:49 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: 07/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2024
Section Cited
CCR
87468.2(a)(1)

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(a) In addition...elderly shall have all of the following personal rights:(1)To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications...and meetings of resident and family groups.
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House manager agreed to removed the recording devices in the resident rooms, and conduct a training on the use of video cameras in the facility.
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This requirment was not met as evidenced by: Based on observation and interview R1 and R2 have a video monitor with audio placed in their private rooms. This poses a potential saftey, health or personal rights risk to residents in care.
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Proof of this is due by the POC due date.

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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: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/18/2024 11:49 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: 07/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/19/2024
Section Cited
CCR
87355(e)(2)

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(e) All individuals subject to a criminal record review...shall prior to working...(2)Request a transfer of a criminal record clearance...This requirement was evidenced by:
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The hosue manager agreed to send a transfer for S1 by the POC due date.
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Based on records review, it was found that S1 was not associated to the facility. This poses an immediate, health, safety or personal rights risk to residents in care.
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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: Janira ArreolaTELEPHONE: 951-233-6759
LICENSING EVALUATOR SIGNATURE:
DATE: 07/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3