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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604493
Report Date: 03/20/2023
Date Signed: 03/20/2023 01:55:07 PM

Document Has Been Signed on 03/20/2023 01:55 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 VICTORIA LLCFACILITY NUMBER:
374604493
ADMINISTRATOR:QUEZON, SIMONFACILITY TYPE:
735
ADDRESS:1537 TIBIDABO DRTELEPHONE:
(323) 803-3284
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 2DATE:
03/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Staff, Victoria MirandaTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Janira Arreola and Sara Martinez conducted an unannounced annual required visit on 3/20/2023 at 10:30 a.m. LPA was granted entry and met with Staff, Victoria Miranda who was informed of the purpose of the visit. At the time of the visit there was (1) staff and (2) clients present.

The facility is a one story home with (5) bedrooms and (5) bathrooms for clients. The clients served are adults between the ages of 18-59. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted staff and client interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms had the hand washing signs with the steps on how to properly wash hands. LPA observed gloves and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan and found all required infection control measures.



Physical Plant: LPA observed the client bedrooms. Physical plant, floors, windows, and doors were observed to need more consistent cleaning as the LPAs observed that the C1's bedroom and bathroom were unkempt . Fixtures and furniture were present, drawers and cabinet doors were observed to be broken or in need of repair in the client restrooms and kitchen. This will be documented on a technical advisory note. The outdoor area was observed to be free of hazards. LPAs observed the facility outdoor furniture for clients to sit outdoors. Laundry room was observed to be in the garage and was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The LPAs did observed razor blades in a clients private bathroom and laundry soap in the garage to be unlocked. The LPAs reviewed the IPP plans for the clients and found that the clients are "independent" and do their own laundry per staff.

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 did not met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Type B deficiency was documented along with a plan of correction for this.

Care & Supervision/Administration: Adequate staff are present for the supervision of clients. Emergency exiting plans, telephone numbers and personal rights were found posted in the facility. The facility fire department phone number was found to be out of order. The LPA documented technical advisory note for the staff to update this information on the posted emergency number list. The listed administrator, possesses a current administrator's certificate.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2023
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 VICTORIA LLC
FACILITY NUMBER: 374604493
VISIT DATE: 03/20/2023
NARRATIVE
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Record Review and Resident/Staff Files: LPA reviewed (2) staff files and (2) client files. LPA requested the LIC500 and was informed by staff that they were unable to locate it. LPA documented a technical advisory note for this. All staff have criminal clearance and updated training along with CPR/First Aid Certification, except for the administrator where it was found that the CPR certificate was expired on 6/2022. The facility will receive a type B deficency for this. Two (2) client files were reviewed, and possessed all required paperwork, except fo the needs and services plan. LPA will document type B deficiency for this along with the plan of correction.

Health Related Services/ Incidental Medical Services: All client medication was locked in a medication cabinet and were locked in the refrigerator. LPA reviewed client medications for (2) clients and found all medication listed on centrally stored lists and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The facility will receive a type B deficiency for not having an updated LIC610D with evacuation procedures, emergency storage of food, and emergency supplies. LPA was informed that the facility had conducted a fire drill as required. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where a copy of this report along with LIC809-D pages, and appeal rights, were provided to Staff, Victoria Miranda.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 03/20/2023 01:55 PM - It Cannot Be Edited


Created By: Janira Arreola On 03/20/2023 at 01:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VILLA VICTORIA LLC
FACILITY NUMBER: 374604493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above with (1) staff who did not have an updated CRP/First aide training on file for LPAs to review.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2023
Plan of Correction
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The adminisrtator agreed to send the cpr updated certification to the LPA by the POC due date.
Type B
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above with (2) client files that did not have the needs and services plan for LPAs to review. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2023
Plan of Correction
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The administrator agreed to send to the LPA the needs and services plan to the LPA by the POC 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.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 03/20/2023 01:55 PM - It Cannot Be Edited


Created By: Janira Arreola On 03/20/2023 at 01:10 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VILLA VICTORIA LLC
FACILITY NUMBER: 374604493

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above with observed perishables and non-perishables that were not in the required amounts at the facility.This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2023
Plan of Correction
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The administrator agree to send the LPA photos of the purchased food by the POC due date.
Type B
Section Cited
CCR
80023(a)
Disaster & Mass Casualty Plan
(a) Each licensee shall have and maintain on file a current, written disaster and mass casualty plan of action.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above with the facility plan for diaster and emergency being the outdated LIC 610D form. The adminsitrator stated that they did not have a uodated LIC610D form. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2023
Plan of Correction
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The administrator agree to send an updated form to the LPA by the POC 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.
SUPERVISOR'S NAME:Joel Esquivel
LICENSING EVALUATOR NAME:Janira Arreola
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2023


LIC809 (FAS) - (06/04)
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