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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374602650
Report Date: 02/15/2024
Date Signed: 02/15/2024 01:03:06 PM

Document Has Been Signed on 02/15/2024 01:03 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SANTOS VILLA ANNEFACILITY NUMBER:
374602650
ADMINISTRATOR:EUGELYN SANTOSFACILITY TYPE:
735
ADDRESS:1925 VERMEL AVENUETELEPHONE:
(760) 294-7137
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY: 4CENSUS: 4DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Romina Mas, DSP I TIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to conduct a required 1 year visit. LPA was greeted and granted entry by DSP Romina Mas, where LPA explained the purpose of the visit. Romina has obtained criminal record clearance and is associated to the facility. The Administrator was unavailable to come to the facility for LPAs visit. At the time of the visit there was one (1) staff and one (1) resident present, as they had an on site doctors appointment scheduled during LPAs visit.

LPA conducted a tour of the interior and exterior of the facility. The facility was observed to be clean, clutter and odor free. The bathrooms were equipped with grab bars and toilets were observed to be in working order. However there was a brown metal chair observed in the shower, that was confirmed to be used by residents. The chair was removed at the time of LPAs visit. Facility is to follow up in regards to obtaining a proper shower chair. The P&I was counted for all four residents and all monies were presented and accounted for. LPA discussed the need for the resident appraisals/needs and services plans to be reviewed and updated accordingly.

The smoke and carbon monoxide detectors were tested and found to be operable. The emergency disaster drills are being conducted every six (6) months, the last fire drill was conducted on 9/23/23. The hazardous chemicals, medications and sharps were observed to be locked and inaccessible to residents in care. There are two bathrooms designated for residents use. The water temperature was checked and measured at 116.9-117.1 degrees, which is within regulatory limits. There were no bodies of water, firearms and/or ammunition on the premises. In the backyard there is a shed that is used for storage. LPA will send a copy of the PUB475 to the facility via email as it was not observed at the facility.

LPA observed the following deficiencies:
LPA observed for there to be old work out equipment in the backyard that is rusted. The back resident bedroom resident #1 (R1) room, was observed to have chips, tiny holes and fragments off of their wall
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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 02/15/2024 01:03 PM - It Cannot Be Edited


Created By: Javina George On 02/15/2024 at 11:53 AM
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: SANTOS VILLA ANNE
FACILITY NUMBER: 374602650

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in 1 out of 1 times, as R1's room is in disrepair, there is old rusted workout equipment and damaged chair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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The licensee agrees to make the necessary repairs (cleaning the cob webs, and painting the room), remove the chair and equipement. Proof of correction is to be provided by 5pm on the due date indicated.
Type B
Section Cited
CCR
80088(c)
Fixtures, Furniture, Equipment, and Supplies
(c) Fireplaces and open-faced heaters shall be inaccessible to clients to ensure protection of the clients' safety.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as there are four residents in care that all of have access to the fireplace, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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The licensee agrees to properly secure the fireplace and remove the paintings and covid postings that cover the entrance of the fireplace. Proof of corrections is to be submitted to the department by 5pm on the due date indicated.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024


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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SANTOS VILLA ANNE
FACILITY NUMBER: 374602650
VISIT DATE: 02/15/2024
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missing. The walls need to be repainted. In addition there were cob webs and small black bugs on in the corner of the room above and along the side of the window sill. In the common area there is a brown suede chair with the stuffing showing as the facility cat has scratched up the side of the chair.

The fireplace is screened, there is no glass or cover preventing the residents from having access. There are resident paintings and covid posters on a board covering the entrance to the fireplace. Per staff the fireplace is not being used.

The deficiencies are being cited in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 6).

An exit interview was conducted, and a copy of appeal rights were provided to Romina Mas. DSP.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
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