374603847-5-20-2024-18-AS-JGEE-D5FU8H-20240520152134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603847
Report Date: 05/20/2024
Date Signed: 05/20/2024 03:21:39 PM

Document Has Been Signed on 05/20/2024 03:21 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:	VILLA VERDE HOME		FACILITY NUMBER:	374603847
ADMINISTRATOR/ DIRECTOR:	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:	05/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:14 PM
MET WITH:	Maria Dineros, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Javina George conducted an unannounced annual required visit. 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 (5) clients present.

The facility is a single story home with (5) bedrooms and (2.5) bathrooms with 2 laundry rooms and 2 attached garages. The residents 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 staff interviews and attempted client interviews. Below are the following observations made during today's visit.

The facility was observed to be clean and clutter free. The resident bedrooms were free from obstruction and had adequate lighting. Each resident bedroom contains a Hoyer lift, as well as a locked medication cabinet. The Medication Authorization Records (MARs) are in individual binders on the cabinet inside the hallway. The facility was observed to have an organized and stocked supply room as well as an ample amount of PPE supplies.

The smoke and carbon monoxide detectors are in a combined device were tested and were observed to be operable. There are no known guns or ammunition stored on the premises. There are no pools or bodies of water on the premises. The hot water temperature was checked and was found to be within regulatory limits measuring at 109 degrees F. The last emergency disaster drill was conducted on 4/22/24.

The facility currently has (1) resident that eats solid foods, all other residents utilize a Gastronomy tube (G-tube). LPA observed a sufficient supply of formula for available for G tube feedings. The facility food supply met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

LPA observed for the facility to have the required postings such as license, emergency disaster plan, personal rights and Department complaint poster to be posted throughout the facility. LPA reviewed (2) staff files and training. All staff have criminal clearance and were associated to the facility. Each staff was

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024

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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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: VILLA VERDE HOME	FACILITY NUMBER: 374603847
	VISIT DATE: 05/20/2024

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observed to have updated training along with valid CPR/First Aid Certification expiring on 4/5/26. Resident files were reviewed and observed to have all the required paperwork. The resident files reviewed had current health care plan's as recent as 4/17/24. All resident's personal and incidental funds were verified.

Based on today's visit there were no deficiencies cited at the time of the visit.

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

SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:	DATE: 05/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024

LIC809 (FAS) - (06/04)

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