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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604493
Report Date: 03/06/2025
Date Signed: 03/06/2025 03:25:40 PM

Document Has Been Signed on 03/06/2025 03:25 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 VICTORIA LLCFACILITY NUMBER:
374604493
ADMINISTRATOR/
DIRECTOR:		QUEZON, SIMONFACILITY TYPE:
735
ADDRESS:1537 TIBIDABO DRTELEPHONE:
(323) 803-3284
CITY:ESCONDIDOSTATE: CAZIP CODE:
92027
CAPACITY: 6CENSUS: 4DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:45 PM
MET WITH:Victoria Miranda, CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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On 03/06/25 Licensing Program Analyst(LPA) Javina George made an unannounced visit to the facility to conduct a 1 year required inspection. LPA was greeted and granted entry by Caregiver Victoria Adriano where LPA explained the purpose of the visit. LPA conducted a tour of the interior and exterior areas of the facility. LPA observed for there to be gnats flying around throughout the facility mainly inside the kitchen area above the sink. LPA observed for there to be a trap to catch the pests. Per caregivers this is due to the fruit trees that are outside. Deficiency cited.

The food supply was observed to be sufficient. The hot water was tested and was found to measure at 122 degrees Fahrenheit. The hot water heater was adjusted and was found to measure at 120, within regulatory limits. Records review: The client files had the required documentation, staff files reviewed showed for Staff #1 to have expired CPR certification. However S1 completed the training during LPAs visit and was issued a new certificate that expires on 3/6/27. In addition Staff #2 was found to be cleared but not associated to the facility. LPA observed for there to be a completed LIC9182, proof was submitted showing that an attempt was made to associate S2 therefore, no citation issued.

The fire extinguishers were last serviced April 2024. There are no known guns or ammunition on the premises. There were no pools or bodies of water observed. The medications are being given according to physician's instructions based on the medication authorization record. The emergency disaster drills are being conducted on a quarterly basis, with the last drill being conducted 12/16/24 with a drill being due March 2025. The smoke and carbon monoxide detectors were tested and found to be operable. The facility annual fees are due by 03/23/25, LPA provided PIN846595, should the Licensee wish to pay electronically. The governing body was observed to be active and in good standing.
The clients do not have any personal and incidental funds therefore they were not reviewed during today's visit. The facility was observed to not have a supply of personal hygiene items available for client use other than 2.5 tubes of toothpaste. Deficiency cited
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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 VICTORIA LLC
FACILITY NUMBER: 374604493
VISIT DATE: 03/06/2025
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Based on today's inspection a citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 6) on the attached 809D.

An exit interview was conducted and a copy of this report, 809D, appeal rights, LIC9098-Proof of Corrections form and LIC811-Confidential names list was reviewed and provided to Caregiver Victoria Miranda.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Javina George
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/06/2025 03:25 PM - It Cannot Be Edited


Created By: Javina George On 03/06/2025 at 03:10 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: 03/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

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 in 1 out of 1 times which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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The Licensee agrees to have an exterminator to come to the facility and develop a treatment plan to mitigate the pest problem. Proof of POC is to be submitted to the department by 5pm on the due date indicated.
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 and interview, the licensee did not comply with the section cited above in 4 out f 4 persons which poses a potential health, safety and rights risk to persons in care.
POC Due Date: 03/20/2025
Plan of Correction
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The Licensee agrees to purchase hygiene items for the clients to use as needed. Proof of POC is to be submitted to the department by5pm on the due date indicated.
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:Tricia Danielson
LICENSING EVALUATOR NAME:Javina George
LICENSING EVALUATOR SIGNATURE:
DATE: 03/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/06/2025


LIC809 (FAS) - (06/04)
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