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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802121
Report Date: 10/08/2021
Date Signed: 10/08/2021 04:42:31 PM

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 GARDENSFACILITY NUMBER:
425802121
ADMINISTRATOR:JENNIFER FIDELFACILITY TYPE:
740
ADDRESS:1510 CALLE MIROTELEPHONE:
(805) 430-8906
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:6CENSUS: 3DATE:
10/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Jane Castaniaga, Licensee/AdministratorTIME COMPLETED:
12:00 PM
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On 10/8/21 at 9:10 AM, Licensing Program Analyst (LPA) Toan Luong arrived at the facility and contacted Licensee/Administrator Jane Castaniaga via telephone to perform a facility risk assessment. LPA conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. LPA met with house staff and explained the purpose of the visit. Licensee/Administrator Jane Castaniaga arrived at the facility at 10:50 AM to conduct inspection with LPA. LPA explained purpose of the visit to licensee.

House staff took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department.

The facility is a Residential Care Facility for the Elderly. During the facility tour, LPA advised posting signs of CDSS PINs and have PINs readily accessible to residents, visitors, and staff. Administrator on file was absent at the facility, and a substitute was not on-site. LPA advise training and assigning house staff as a substitute, or prompt communication to substitute to ensure coverage. LPA recommended administrator have staff fit-tested with N95 masks. LPA observed fire extinguisher was dated September 2020 and recommended fire extinguisher to be serviced.

LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with Licensee to satisfaction.

Exit interview was conducted. No deficiencies were cited. Report emailed to Licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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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