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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604493
Report Date: 03/08/2024
Date Signed: 03/08/2024 01:44:44 PM

Document Has Been Signed on 03/08/2024 01:44 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 AC/SC, 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: 4DATE:
03/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Administrator, Simon QuezonTIME COMPLETED:
01:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jacqueline Shaw Ross conducted an unannounced annual required visit on 3/8/2024. 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 (2) staff and (4) clients present. Administrator, Simon Quezon arrived shortly.

The facility is a one story home with (5) bedrooms and (4) 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:

Physical Plant: The home has a living room, kitchen and dining area, a room for staff, garage and a backyard area. The dining and living room areas are clutter free and appropriately furnished. The exterior pathways of the home were observed to be clutter free with no obstructions present. There are no pools or other bodies of water located at the home. Interior passageways were clear and free of obstruction. The bedrooms are completely furnished with a bed, night stand, dresser, chair, adequate lighting and privacy is available. Night lights were observed in the hallways. The facility currently has linens, towels and a sufficient amount of hygiene products for clients. LPA observed the following deficiencies:



-Two of the client bedrooms were missing mattress pads and bedsheets. Deficiency cited.
-Two of the client bathrooms were missing paper towels/hand towels and toilet paper. Deficiency cited.
-The kitchen contained hazardous cleaning agents stored in an unlocked cabinet under the kitchen sink. Deficiency cited.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 03/08/2024 01:44 PM - It Cannot Be Edited


Created By: Jacqueline Shaw Ross On 03/08/2024 at 12:19 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: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, two cleaning solutions were stored in an unlocked cabinet. The facility did not comply with the section cited above in [2] out of [2] objects which posed a potential health and safety risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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Staff immediately removed cleaning items and stored them in a locked cabinet in the garage during the visit. Licensee will provide refresher training on storage of toxic items and provide written proof of training log to the Department by POC date of 3/22/2024.
Type B
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in [2] out of [4] persons which posed a potential health and personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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The facility immediately provided proper mattress pad and bedsheets on resident's beds. Licensee will provide refresher training to staff of the deficiency and will provide proof of training to the department by the POC date of 3/22/2024.
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:Jazmond D Harris
LICENSING EVALUATOR NAME:Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/08/2024 01:44 PM - It Cannot Be Edited


Created By: Jacqueline Shaw Ross On 03/08/2024 at 12:19 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: 03/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(5)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (5) Feminine napkins, nonmedicated soap, toilet paper, toothbrush, toothpaste, and comb.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the facility did not have toilet paper, nor paper towels/hand towels in resident's personal bathrooms. The licensee did not comply with the section cited above in [2] out of [4] persons) which posed a potential health or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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The facility immediately placed paper towels and toilet paper in the residents' bathrooms during the visit. Licensee will conduct a refresher training related to this plan of correction and will provide proof of training to the Department by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Jazmond D Harris
LICENSING EVALUATOR NAME:Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024


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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLA VICTORIA LLC
FACILITY NUMBER: 374604493
VISIT DATE: 03/08/2024
NARRATIVE
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According to Administrator, there are no weapons stored in the home. The hot water temperature was tested and measured at 115 degrees Fahrenheit, which was within regulatory limits. Outdoor areas had sufficient room for activities and leisure. Smoke and Carbon Monoxide detectors were tested and operable. The phone number designated for the facility is (760) 975-3013. The facility has an alarm system.

Food Service: LPA observed facility kitchen had the ability to prepare food in a 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.

Record Review and Resident/Staff Files: LPA reviewed (2) staff files and (2) client files. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Two (2) client files reviewed contained all required paperwork as well. LPA was informed as of now, none of the clients have Personal and Incidental funds.

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 and observed all facility exits were clear from obstructions. LPA was informed the next emergency drill is scheduled for today.

An exit interview was conducted where a copy of this report along with LIC809-D pages, and appeal rights, were provided to Administrator, Simon Quezon.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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