415600222-12-16-2023-14-AS-APAA-CYL772-20231216202359

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600222
Report Date: 12/16/2023
Date Signed: 12/16/2023 08:24:13 PM

Document Has Been Signed on 12/16/2023 08:24 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	BAYVIEW VILLA		FACILITY NUMBER:	415600222
ADMINISTRATOR:	LONCAR, LJUBICA VIOLET		FACILITY TYPE:	740
ADDRESS:	777 BAYVIEW DRIVE		TELEPHONE:	(650) 596-3489
CITY:	SAN CARLOS	STATE: CA	ZIP CODE:	94070
CAPACITY:	47	CENSUS: 15	DATE:	12/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Violet Loncar		TIME COMPLETED:	04:00 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	On 12/16/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA met with Supervising Medication Technician (SMT), Danilo Rubios and explained the purpose of the visit. LPA asked that SMT Rubios call the Facility Designated Representative (FDR), Khin Thida and Licensee and Administrator (AD), Violet Loncar to inform them that CCL was present at this time. Shortly after, LPA met with FDA and explained the purpose of the visit. This facility is licensed to serve 47 residents who are 60 and over all of which may be non-ambulatory. This facility has a dementia plan on file and has a hospice waiver for 8. Current census was 15. It was learned that of the 15 residents, 5 are residing in assisted living and 6 are fresiding in memory care. There are currently 2 residents on hospice and 3 residents receiving home health services. LPA reviewed 6 resident files. LPA reviewed 3 staff files. The Facility Designated Administrator current holds an active administrator certificate #6004504740 and expires on 1/20/2025. The interior of the physical plant was in good condition and sanitary. Fire extinguishers appeared to have been annually inspected by Reliable Fire Company and is valid until 04/12/2024. The kitchen area was toured. LPA observed a non-perishable and perishable foods in the cabinets and refrigerator. Additional perishable food supplies were identified in the garage. LPA observed a locked centralized stored medication cabinet located in the kitchen. Along with the administrator, the LPA observed, reviewed, and compared resident medication and medication dispensing logs. First Aid Kit was present and contained all of the required components. A tour of the bathrooms was conducted. Hot water temperature was measured and observed to be within the required range of 105-120 degrees. A linen closet was located in the hallway and presented a sufficient amount of linens to adequately supply and meet the needs of the residents at this time. A tour of the bedrooms was conducted. Resident furniture was observed to be sufficient to meet their needs at this time. Laundry area was toured. Laundry detergent, bleach, and all other cleaning supplies were observed to be locked and made inaccessible to the residents at this time

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023

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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BAYVIEW VILLA	FACILITY NUMBER: 415600222
	VISIT DATE: 12/16/2023

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Common areas were toured. Living room, dining area and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time.

A tour of the garage was conducted. Additional perishable food supplies were identified.

The exterior of the physical plant was toured. Perimeter fence was observed to be stable and gates were in good repair.

The following forms and documents were requested to be updated and submitted into CCL

-LIC 308

-LIC 400

-LIC 500

-LIC 610

-Liability Insurance

As a result of this visit, no deficiencies were observed or cited during this annual visit. An exit interview was conducted and copy of the 809 and 809-C was provided to the facility at the end of this visit.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2023

LIC809 (FAS) - (06/04)

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