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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603847
Report Date: 05/02/2022
Date Signed: 05/02/2022 11:31:52 AM

Document Has Been Signed on 05/02/2022 11:31 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VILLA VERDE HOMEFACILITY NUMBER:
374603847
ADMINISTRATOR:ANDRES, GREGORYFACILITY TYPE:
734
ADDRESS:2286 VILLA VERDE ROADTELEPHONE:
(760) 317-1644
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY: 5CENSUS: 4DATE:
05/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 PM
MET WITH:Administrator- Maria DinerosTIME COMPLETED:
11:35 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced Case Management regarding a death report received at the regional office on 04/25/2022. LPA met with and was granted entry by Administrator, Maria Dineros, who was informed of the purpose of the visit. At the time of the visit there were 4 residents, and 7 staff members present.

LPA requested and received the following documents:

· ID and Emergency Information (LIC 624A)


· Admission Agreement
· Medical Orders – from 4/2022
· Most recent resident Appraisal
· Resident Appraisal from
· Updates and Prior Individual Health Care Plan (IHCP)
· Quarterly Progress Notes
· Medication Records
· Personal Property Record
· Weight Record
· Laboratory Paperwork
· Incident reports leading up to the death

Most Recent Physician's report was not at the facility and Administrator was advised to e-mail as soon as possible.

LPA provided a copy of this report to Administrator, Maria Dineros
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/26/2022
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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