374603847-5-24-2023-18-AS-JARA-CS5RC8-20230524125354

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603847
Report Date: 05/24/2023
Date Signed: 05/24/2023 12:54:19 PM

Document Has Been Signed on 05/24/2023 12:54 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 VERDE HOME		FACILITY NUMBER:	374603847
ADMINISTRATOR:	ANDRES, GREGORY		FACILITY TYPE:	734
ADDRESS:	2286 VILLA VERDE ROAD		TELEPHONE:	(760) 317-1644
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92029
CAPACITY: 5		CENSUS: 5	DATE:	05/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator Maria, Dineros		TIME COMPLETED:	01:15 PM

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Licensing Program Analysts (LPAs) Janira Arreola and Janette Romero conducted an unannounced annual required visit on 5/24/2023 at 09:45 a.m. LPA was granted entry and met with Administrator, Maria Dineros, who was informed of the purpose of the visit. At the time of the visit there was (5) staff and (4) client present.

The facility is a one story home with (5) bedrooms and (3) bathrooms with 2 attached garages. No pools or firearms are being kept at the facility. The clients served are adults between the ages of 18-59 with special health care needs. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and attempted client 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. LPA reviewed staff records and found that all staff had infection control training.

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 good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature 107F.

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. The facility currently has (1) resident that eats solid foods, all other residents utilize a g-tube.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients during the visit. LPA also reviewed the staff scheduled showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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 VERDE HOME	FACILITY NUMBER: 374603847
	VISIT DATE: 05/24/2023

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Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) client files were reviewed, and possessed all required paperwork. LPA verified the administrator had sent documentation for an administrator change. The LPAs will follow up on processing the paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked in residents rooms. LPA reviewed client medications for (2) client and found all medication listed on MARS and all required labeling was found to be in place. LPAs also observed hoyer lifts and medical supplies such as feeding tube supplies and sanitizing supplies.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The facility does not currently have a mass casualty plan, technical advisory note was documented for this. 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 and first aid kit with all required items.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to the Administrator, Maria Dineros.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:	DATE: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC809 (FAS) - (06/04)

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