374602650-2-6-2025-18-AS-JARA-DDMSHC-20250206125319

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374602650
Report Date: 02/06/2025
Date Signed: 02/06/2025 12:53:53 PM

Document Has Been Signed on 02/06/2025 12:53 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 ANNE		FACILITY NUMBER:	374602650
ADMINISTRATOR/ DIRECTOR:	EUGELYN SANTOS		FACILITY TYPE:	735
ADDRESS:	1925 VERMEL AVENUE		TELEPHONE:	(760) 294-7137
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92029
CAPACITY: 4		CENSUS: 4	DATE:	02/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Staff, Romina Mas		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced Annual Required Visit. LPA was granted entry by and met with Staff, Romina Mas. One of the Administrator, Christopher Santos was available over the phone during the visit. The administrator and staff were informed of the purpose of the visit. During the time of the visit there was (1) clients and (2) staff present. The facility is a (1) story home with (4) bedrooms and (2) bathrooms for clients, and (2) bedrooms and (1) bathroom for staff. There are no bodies of water, weapons or fire arms kept at the facility. LPA conducted interviews, records review and a walk through. LPA observed the kitchen had equipment in good working condition. The facility meets the (2) day perishable and (7) day non-perishable supply of food. The knifes and cleaning supplies were kept locked. The outdoor area was observed to be free of hazards and has an emergency exit. LPA observed the resident bedrooms had the required furniture and the bathrooms have grab bars and hygiene supplies for residents. The hot water temperature was recorded and the carbon monoxide and smoke alarms are in working condition. There are cleaning supplies to do regular cleaning of the facility. Required postings are found in the living room, and emergency and PPE supplies were kept in a staff room.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: SANTOS VILLA ANNE	FACILITY NUMBER: 374602650
	VISIT DATE: 02/06/2025

NARRATIVE

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LPA reviewed (4) resident records which possessed all required paper work.

The resident medication was kept locked in a cabinet in the kitchen. LPA reviewed resident medications which were accounted for on the centrally stored medication lists and Medication Administration Records (MAR).

LPA reviewed (4) staff records, the current administrator did not have current CPR and First aide certificate. The current administrator has a current Administrator's Certificate. LPA reviewed the last conducted fire drill on 9/23/2024 which did not meet the required interval. LPA also observed black spots and humidity smell in the staff restroom. These items are being cited and plans of correction were created with the administrator over the phone for physical plant, fire drill, and personnel requirements. An exit interview was conducted where this report was reviewed and provided.

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/06/2025 12:53 PM - It Cannot Be Edited

Created By: Janira Arreola On 02/06/2025 at 12:30 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: SANTOS VILLA ANNE	FACILITY NUMBER: 374602650
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1565(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 individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. 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 fire drill conducted (4) months ago. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/13/2025
	Plan of Correction
1 2 3 4	The administrator agreed to conducted a fire drill and send documentation and statement acknolegding they have read and understood the section cited above to the LPA by the POC due date.

Type B

Section Cited

CCR

80087(a)

80087 Buildings 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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above with (1) of (3) restroom which contained black spots resembling mold. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/13/2025
	Plan of Correction
1 2 3 4	The administrator agreed to inspect and clean the restroom and keep all restrooms in sanitary condition. Proof of correction is due by the POC due date.

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 Danielson

LICENSING EVALUATOR NAME:

Janira Arreola

LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 02/06/2025 12:53 PM - It Cannot Be Edited

Created By: Janira Arreola On 02/06/2025 at 12:39 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: SANTOS VILLA ANNE	FACILITY NUMBER: 374602650
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80075(f)

(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross. 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 (1) of (4) staff who did nto have a current CPR and first aid certificate during the time of the vsiit. This which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/13/2025
	Plan of Correction
1 2 3 4	The administrator agreed to ensure all staff meet current requirments by auditing staff files. The administror agreed to send a written statment of their procedure for checking staff files are complete and the missing staff CPR and first aid certificate 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:

Tricia Danielson

LICENSING EVALUATOR NAME:

Janira Arreola

LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC809 (FAS) - (06/04)

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