374603462-10-27-2023-18-AS-JSRS-CX23PF-20231027182527

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603462
Report Date: 10/27/2023
Date Signed: 10/27/2023 06:25:34 PM

Document Has Been Signed on 10/27/2023 06:25 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	VILLA MONTICELLO ASSISTED LIVING		FACILITY NUMBER:	374603462
ADMINISTRATOR:	ORLANDO DY		FACILITY TYPE:	740
ADDRESS:	25695 N. CENTRE CITY PARKWAY		TELEPHONE:	(760) 738-1557
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92026
CAPACITY:	29	CENSUS: 18	DATE:	10/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Dolores McGonigal, Senior Team Leader		TIME COMPLETED:	06:30 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) Jacqueline Shaw Ross made an unannounced visit to the facility for the purpose of an annual review. LPA was greeted by Dolores McGonigal, Senior Team Leader and explained the purpose of the visit. The facility has the capacity to serve 29 non-ambulatory elderly residents, ages 60 and above. There is a hospice waiver for 15 residents and the facility has 10 residents receiving hospice care, which is in compliance with the hospice waiver. During today’s visit, a tour of the facility was conducted inside and out. During the inspection, LPA, accompanied by the Senior Team Leader, observed the following: carbon monoxide and smoke alarms were present and operational. Facility records reflect that the last disaster drill was conducted on 7/27/2023. According to the Senior Team Leader, there are no weapons and/or ammunition housed on the facility premises. No pools and/or bodies of water were observed. Exterior and interior passageways were free from obstructions. Lighting was present in the resident units. The indoor temperature measured at 72 degrees Fahrenheit in Building 1 and 73 degrees Fahrenheit in the Main Building during the visit. The facility was stocked with a 2-day supply of perishable food items and a 7-day supply of non-perishable food items. Residents had clean and sufficient bed linens, towels, and washcloths. Residents’ rooms were equipped with the required furnishings. Residents’ bathrooms were observed to be operational. Toilets and showers were observed with grab bars, and resident showers had nonskid mats. Water temperature in a sample of resident bathrooms measured at 115.5 degrees Fahrenheit in Building 1 and 117.6 degrees Fahrenheit in the Main Building, both of which are within the requirement of regulation. There are currently no residents in Building 3.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

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 2

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: VILLA MONTICELLO ASSISTED LIVING	FACILITY NUMBER: 374603462
	VISIT DATE: 10/27/2023

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
26
27
28
29
30
31
32

Continued from LIC 809....

Medications were stored in a locked medication cart and maintained in compliance with label instructions. Medications are dispensed according to physicians orders. A sample of resident records were reviewed, and reviewed records were complete and up to date.

Staff present during the time of the visit had current criminal background clearance, proof of current first aid and CPR training, and staff training. The Administrator’s Certificate for Orlando Dy expires on 6/17/2024 and annual fees are current.

No deficiencies were cited during today’s annual inspection. An exit interview was conducted with Dolores McGonigal, Senior Team Leader and a copy of this report was provided.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross	TELEPHONE: 951-248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2