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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850027
Report Date: 06/23/2020
Date Signed: 06/23/2020 04:27:51 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117
FACILITY NAME:VILLA CARE HOME IFACILITY NUMBER:
425850027
ADMINISTRATOR:VILLAROS, JENNIFERFACILITY TYPE:
740
ADDRESS:938 WEST BUNNY AVENUETELEPHONE:
(805) 928-5654
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:6CENSUS: 5DATE:
06/23/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Jennifer VIllaros, LicenseeTIME COMPLETED:
10:05 AM
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At 8:40 am, Licensing Program Analyst (LPA) Darlene Chavez made an announced pre-licensing televisit to the location listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today's pre-licensing visit was conducted telephonically via Facetime with Jennifer Villaros, Licensee, and Jessica Villaros-Rust, Administrator.

A tour of the physical plant was conducted and the following was noted:
At 8:41 am, LPA Chavez observed all required signage posted in the hallway with emergency plan and telephone numbers, personal rights, theft and loss policy, LTCO poster and CCL Complaint poster. The physical plant is set up for dementia residents’ safety and noted throughout the report.
The facility has 5 bedrooms with 2 full bathrooms, 1 staff bedroom and 1 staff bathroom, a living room, dining room, kitchen, and garage with laundry area, and a fully fenced secured perimeter around the front yard, back yard, and side yard.
Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, doors and screens were checked, all operating properly and in good condition. All exits have auditory alarms to alert staff when someone enters or exits the facility. A working telephone is present. Emergency lighting, supplies, flashlights, batteries, are present. One vehicle is used to transport residents and it is in safe operating condition. The facility does not keep any firearms or ammunition. All passageways and doors are clear and not blocked or obstructed. The physical plant is consistent with the submitted facility sketch/floor plan. The smoke detectors are hard wired throughout the facility and the fire department granted clearance for the facility. There are no issues with Fire Clearance. The fire extinguisher is fully charged. The carbon monoxide detector was tested and fully functional.
Living and dining rooms are clean, safe and sanitary. The facility maintains a comfortable temperature.
The Yards of the facility have outdoor furniture with a covered shaded area for residents. The back and side yards are completely fenced with locked self-latching and self-closing gates.
Continued 809-C
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) -59-343
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: 805-450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117
FACILITY NAME: VILLA CARE HOME I
FACILITY NUMBER: 425850027
VISIT DATE: 06/23/2020
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The backyard has a large area around the facility with access to fruit trees with a fully fenced secured perimeter with locked gates.
The kitchen area was sufficiently stocked with a supply of two-day perishables and seven-day non-perishables. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. The garbage cans are seal properly. Cleaning supplies, pesticides or toxins are kept in a locked cabinet in the garage. All sharp objects are locked in a drawer in the kitchen. Freezer temperature was 0 degrees F and refrigerator temperature was 37 degrees Fahrenheit. Dishes, glasses and utensils are sufficient in supply, clean, and in good condition. The hot water measured 115 degrees F at 9:44 am.
The resident rooms are adequately dressed with sheets, pillowcase, mattress pad, and blankets which are all in new condition. There is at least one chair, night stand, dresser and sufficient lighting for each resident. The bathrooms were checked for cleanliness and proper operation. All handrails/grab bars are securely fastened and present for the toilets and showers. Bathrooms have non-slip bottoms on showers. The hot water temperature was measured in both resident restrooms. At 8:57 am, Bathroom #1 measured at 110 degrees F, and at 9:37 am, Bathroom #2 at 105 degrees F. Towels and washcloths are not shared and paper towels are supplied in each bathroom. The facility has sufficient amounts of supplies for personal hygiene which is provided by the Licensee.. There is enough linen available to change weekly or more as needed.
Medications are locked in a cabinet in the kitchen. First Aid has all proper items.
Resident records and staff records are stored in a file cabinet in the kitchen.
Dementia Clients will have a wondering management alert that will sound when exiting the building at all exits and alarms will sound if locked gates are opened.

A telephonic exit interview was conducted with Jennifer Villaros and an electronic copy of the report was emailed for signature, to be returned to LPA Chavez via email or fax.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) -59-343
LICENSING EVALUATOR NAME: Darlene ChavezTELEPHONE: 805-450-0283
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2