425801016-7-21-2022-29-AS-KKOS-CGJW4F-20220721165729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425801016
Report Date: 07/21/2022
Date Signed: 07/21/2022 04:58:01 PM

Document Has Been Signed on 07/21/2022 04:58 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VILLA RIVIERA		FACILITY NUMBER:	425801016
ADMINISTRATOR:	CAROL PRAGER		FACILITY TYPE:	740
ADDRESS:	1621 GRAND AVENUE		TELEPHONE:	(805) 568-5840
CITY:	SANTA BARBARA	STATE: CA	ZIP CODE:	93103
CAPACITY:	20	CENSUS: 7	DATE:	07/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Carol Prager, Administrator		TIME COMPLETED:	04:30 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) Kristin Kontilis conducted an unannounced on-site one-year Infection Control Inspection and Annual visit to the above-named facility. LPA arrived at 10:55 AM and was greeted by Meagan De Carlo, Assistant Administrator. Administrator Carol Prager was present during the inspection. At the time of arrival, there were 7 residents in care and 3 staff on duty. A Mitigation Plan has been submitted to CCLD. LPA explained the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) and is home to non-ambulatory residents with a Dementia diagnosis and a Hospice Waiver for four residents. Currently, there is one resident on hospice. Entrance interview conducted: A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster, bill of rights and Resident’s Rights. LPA inspected the two-story facility for fire safety, personal accommodations, and food service. The facility maintains a comfortable room temperature. First aid kit was observed to be complete. The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. There are seven (7) fire extinguishers on the premises last serviced on 12/6/2021. There is a total of 20 carbon monoxide detectors and approximately thirty (30) smoke alarms throughout the facility. The smoke alarms automatically alert the local fire department when activated. Fire drills are conducted approximately three (3) times each month. Snacks and beverages are available for residents in care upon request. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean. Cleaning agents and the toxic chemicals are kept in a supply room. Medications and sharps are kept in a cabinet located in the Nurse’s station. The facility has an outdoor deck with table and chairs and a ramp for access to other areas of the facility. The outdoor deck is conducive for outdoor visitations. Please continue to 809-C, Pg 2.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA RIVIERA	FACILITY NUMBER: 425801016
	VISIT DATE: 07/21/2022

NARRATIVE

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There are fifteen (15) private bedrooms with private bathrooms located on the upper floor of the facility. There are five (5) private bedrooms are located on the first floor. Bedrooms on the first floor have Jack and Jill bathrooms between each room. All of the bedrooms are furnished with lights and nightstand lamps to provide sufficient lighting.
Interviews revealed a home care agency provides care and supervision to one (1) resident in care. LPA reviewed Department of Social Services, Community Care Licensing Division, Licensing Information System (LIS), Facility Personnel Report summary. LPA determined one (1) staff member from the home care agency currently works in the facility and was not associated to the facility prior to providing staffing assistance.
Administrator stated the home care agency staff member works with Resident 1 (R1) works approximately 2-4 days per week for approximately four (4) hours each shift. Administrator stated the home care agency staff member has worked at the facility for approximately 4 years providing care, supervision, and companionship to R1.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Due to technical issues, Facility Evaluation Report was emailed to Administrator for signature.
Exit interview conducted. Copy of report and Appeal Rights emailed to Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/21/2022 04:58 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA RIVIERA	FACILITY NUMBER: 425801016
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(1)(2)

87355(e)(1)(2) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews conducted, the licensee did not comply with the section cited above by one home care agency staff member who has worked at the facility for approximately four years has not been associated to the facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/22/2022
	Plan of Correction
1 2 3 4	Administrator agrees home care agency staff member will not work in the facility until properly associated to the facility.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Kristin Kontilis	TELEPHONE: (805) 689-2787
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

LIC809 (FAS) - (06/04)

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