372008431-5-26-2023-18-AS-JARA-CS7W5R-20230526165935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 372008431
Report Date: 05/26/2023
Date Signed: 05/26/2023 05:00:23 PM

Document Has Been Signed on 05/26/2023 05:00 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 ESPERANZA II		FACILITY NUMBER:	372008431
ADMINISTRATOR:	RADJENOVIC, MIRJANA		FACILITY TYPE:	735
ADDRESS:	821 EAGLES NEST GLEN		TELEPHONE:	(760) 741-5424
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92027
CAPACITY: 6		CENSUS: 5	DATE:	05/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:59 PM
MET WITH:	Licensee, Mirjana Radjenovic		TIME COMPLETED:	05:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 5/26/2023 at 02:54 p.m. LPA was granted entry and met with Licensee, Mirjana Radjenovic who was informed of the purpose of the visit. At the time of the visit there was (1) staff and (4) clients present.

The facility is a two story home with (6) bedrooms and (5) bathrooms with attached garage. No pools or firearms are being kept at the facility. The facility is licensed for the first floor only for clients with (4) bedrooms and (3) bathrooms. The clients served are adults between the ages of 18-59. The facility is not vendorized with a regional center. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements.

Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed outdoor furniture and shaded area for clients. Laundry equipment was observed to be in working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients in locked kitchen drawer. The smoke detector and carbon monoxide were operational, and the hot water temperature 105F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator has submitted their administrator's certificate and is pending renewal.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 ESPERANZA II	FACILITY NUMBER: 372008431
	VISIT DATE: 05/26/2023

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Record Review and Resident/Staff Files: LPA reviewed (4) staff files and training. All staff have criminal clearance. The LPA was informed by the licensee that back up staff do not have training documented for (2) staff. LPA also reviewed the last CPR and First aid training expired in 2020. The facility is receiving a type B citation for this. LPA documented deficiency and plan of correction with licensee. Two (2) client files were reviewed, and LPA found they possessed all the required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in closet. LPA reviewed client medications and reviewed the facility's system for reviewing medication. All required labeling and medication was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan, this will need to be update to a new LIC610D. LPA reviewed documentation showing the facility's last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in the and first aid kit.

An exit interview was conducted where a copy of this report along with deficiency and appeal rights were reviewed and provided to the Licensee, Mirjana Radjenovic.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/26/2023 05:00 PM - It Cannot Be Edited

Created By: Janira Arreola On 05/26/2023 at 04:22 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VILLA ESPERANZA II	FACILITY NUMBER: 372008431
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80022(e)(4)

Plan of Operation

(e) If the licensee intends to admit or care for one or more clients who rely upon others to perform all activities of daily living, the plan of operation must also include a statement that demonstrates the licensee's ability to care for these clients. The evidence of ability may include but not be limited to: (4) Documentation of training the licensee and/or staff have completed specific to the needs of these clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with (2) staff files that were missing documented training. Licensee stated they had no documented training for these staff. LPA review CPR training and found that all staff had expired training from 2020. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2023
	Plan of Correction
1 2 3 4	The licensee agreed to send a statement asserting that there are qualified back up staff, and agreed to send uodate CPR certificates for staff by the POC due date.

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.

SUPERVISOR'S NAME:

Joel Esquivel

LICENSING EVALUATOR NAME:

Janira Arreola

LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC809 (FAS) - (06/04)

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