425850212-1-26-2024-29-AS-JOLN-CZV4GM-20240126180547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425850212
Report Date: 01/26/2024
Date Signed: 01/26/2024 06:05:57 PM

Document Has Been Signed on 01/26/2024 06:05 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-CARE HOME III		FACILITY NUMBER:	425850212
ADMINISTRATOR:	RUST, JESSICA		FACILITY TYPE:	740
ADDRESS:	965 ROBERT LANE		TELEPHONE:	(805) 928-1061
CITY:	SANTA MARIA	STATE: CA	ZIP CODE:	93458
CAPACITY:	6	CENSUS: 5	DATE:	01/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:55 PM
MET WITH:	Jessica Rust, Administrator		TIME COMPLETED:	06:15 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) Jenny Olson arrived at the facility unannounced to conduct a required annual visit at 3:55 p.m. When LPA arrived, there were two staff and five residents present. LPA met with Administrator and informed them of the reason for the visit.

LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

Common areas: Living and dining room furniture were observed to be in good condition. At 5 p.m., carbon monoxide detector were tested and operational at the time of the visit. There is a fireplace in the living room, which is screened and inaccessible. LPA observed required postings throughout the common space. The fire extinguisher was charged and serviced 1/25/2024.

The backyard has a covered are for shade and is equipped with furniture for resident use. No bodies of water noted. The washer and dryer are in the garage. The garage is locked.

Restrooms: The two resident restrooms were clean and sanitary and in operating condition with non-skid mats. The bathrooms were sufficiently stocked with soap and paper towels.

Bedrooms: There are four (4) resident rooms, which were furnished. The bathroom is stocked with extra linens and towels.

Records: LPA reviewed resident and staff records from 4- 4:40 p.m. LPA reviewed five (5) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan. Most residents are missing their personal property log. Administrator stated they will complete it if family doesn't going further. Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

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 6

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-CARE HOME III	FACILITY NUMBER: 425850212
	VISIT DATE: 01/26/2024

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
26
27
28
29
30
31
32

LPA reviewed three (3) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. All were complete.

MEDICATIONS: Medications review began at 5:15 p.m. The medications are centrally stored and locked in a closet next to the living room. Medications are labeled and checked for expiration dates.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

At 4:40 p.m., LPA interviewed one (2) staff members and two (2) residents.

During today’s visit, the LPA obtained copies of the following: current liability insurance.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette Olson	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2024

LIC809 (FAS) - (06/04)

Page: 2 of 6