374603908-11-13-2024-18-AS-KBAG-DAYUUY-20241113145419

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603908
Report Date: 11/13/2024
Date Signed: 11/13/2024 06:56:45 PM

Document Has Been Signed on 11/13/2024 06:56 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:	GRAND VILLA		FACILITY NUMBER:	374603908
ADMINISTRATOR/ DIRECTOR:	MALCHOW, LAURA		FACILITY TYPE:	740
ADDRESS:	300 AMPARO DR		TELEPHONE:	(760) 294-2006
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92025
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:50 PM
MET WITH:	House Manager, Colt Baldovino		TIME VISIT/ INSPECTION COMPLETED:	03:15 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) Kathleen Banrasavong arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPA learned that six (6) residents live at this facility. There was two (2) staff members present. The House Manager, Colt Baldovino was advised of the annual and conducted and completed the facility tour. Client Records/Incident Reports/Clients Rights Information: LPA reviewed client records. Six (6) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment, and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. Personnel Records/Training/ Staffing/ Administration: LPA reviewed employee records. Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrative organization. Daniel Malchow, Administrator’s certificate expiration date was 05/05/2025. Laura C. Malchow’s Administrator’s certificate expiration date was 05/06/2025. Food Service: Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a location for sharps in the kitchen.

Jazmond D Harris	TELEPHONE: (951) 248-0318
Kathleen Banrasavong	TELEPHONE: 951-622-3619
	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

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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Document Has Been Signed on 11/13/2024 06:56 PM - It Cannot Be Edited

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: GRAND VILLA	FACILITY NUMBER: 374603908
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interviews, record reviews, the licensee did not comply with the section cited above in six (6) out of six (6) persons not having a current and updated doctor's list of medications, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	The House Manager, Colt Baldovino stated that she will send the LPA an updated list of six residents' doctor's list of medication.

Section Cited

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in six(6) out of six (6) persons's medication which were pre-filled in a container for the next day, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/13/2024
	Plan of Correction
1 2 3 4	The House Manager discarded of the pre-filled medication and stated that she keep all medications in the original containers.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Jazmond D Harris	TELEPHONE: (951) 248-0318
Kathleen Banrasavong	TELEPHONE: 951-622-3619
	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/13/2024 06:56 PM - It Cannot Be Edited

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: GRAND VILLA	FACILITY NUMBER: 374603908
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation,interview, record reviews, the licensee did not comply with the section cited above in four (4) out of four (4) persons not having a current and updated Physician's Report, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	The House Manager stated that she will send to the LPA current and updated Physician's Reports for the four (4) residents by the POC due date.

Section Cited

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (3) A resident medication list for residents with centrally stored medications. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in six (6) out of six (6) persons not having a Doctor's order for medication centrally stored, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/27/2024
	Plan of Correction
1 2 3 4	The House Manager stated that she will send a current and updated list of doctor's prescibed medication list by the 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.

Jazmond D Harris	TELEPHONE: (951) 248-0318
Kathleen Banrasavong	TELEPHONE: 951-622-3619
	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

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: GRAND VILLA	FACILITY NUMBER: 374603908
	VISIT DATE: 11/13/2024

NARRATIVE

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Physical Plant and Safety of Environment/Operational Requirements: LPA toured the facility inside and outside. LPA observed the facility to be clean and in good repair. The facility is maintained at 75 degrees for the client’s comfort. Lighting is sufficient for safety. Water temperature measured 108.0 degrees F. Laundry is done in the laundry room. There is a locked location for storing laundry soap, cleaning supplies and chemicals in the closet in the laundry room. All outdoor and indoor passageways are free of obstruction. Emergency lighting is available. There is a telephone working at this location. LPA dialed the facility’s landline number, which rang and was operable. The LIC 610, emergency disaster plan is maintained. There are no firearms at this facility. There are three (3) secured fireplaces at this facility. There are zero (0) pools at the facility. There is one (1) secured gate that has a self-latching lock located on the northwest side of the house. LPA observed emergency supplies and two (2) first aid kits. The last emergency fire drill was conducted on 09/17/2024.

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 staff had infection control training.

Medications/Health Related Services/Incidental Medical Services: The medications are centrally stored. There is a locked cabinet allocated for medication storage.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

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: GRAND VILLA	FACILITY NUMBER: 374603908
	VISIT DATE: 11/13/2024

NARRATIVE

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LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. LPA observed nine (9) dual smoke detectors and carbon monoxide detectors throughout the facility. There were two (2) fire extinguishers on site, date charged was 08/07/2023.

Pursuant to Title 22 of The California Code of Regulations Division 6, there are four (4) deficiencies observed. An exit interview was conducted, this LIC 809 and the LIC 809-D, appeal rights was reviewed with, and a copy of this report was provided to House manager, Colt Baldovino.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Kathleen Banrasavong	TELEPHONE: 951-622-3619
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC809 (FAS) - (06/04)

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