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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850214
Report Date: 01/26/2024
Date Signed: 01/26/2024 10:21:38 AM


Document Has Been Signed on 01/26/2024 10:21 AM - 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 IFACILITY NUMBER:
425850214
ADMINISTRATOR:RUST, JESSICAFACILITY TYPE:
740
ADDRESS:938 WEST BUNNY AVENUETELEPHONE:
(805) 928-5654
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:6CENSUS: 6DATE:
01/26/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Jessia Rust, Administrator and Jennifer Villaros, LicenseeTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Olson conducted a Case Management - Incident visit to issue deficiencies on an incident the facility self reported. LPA met with Administrator and Licensee and explained the purpose of the visit. LPA toured the facility with Administrator.

CCL received an incident report on 12/7/23 stating that on 12/4/23 a hospice staff observed Staff 1 (S1) used unnecessary roughness or unnecessary force to ensure Resident 1 (R1) remained in a recliner chair as they attempted to get up out of the chair. The incident report states hospice personnel contacted the Licensee to notify them of the incident, and S1 was terminated by the Licensee. LPA interviewed Licensee who stated they reviewed the video footage of the common areas in the facility, and observed S1 “shove/push” R1 back into the recliner. Licensee stated they decided to terminate S1 based on the actions.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

An exit interview was conducted, a copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (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)
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Document Has Been Signed on 01/26/2024 10:21 AM - 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-CARE HOME I
FACILITY NUMBER: 425850214

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2024
Section Cited
CCR
87468.1(a)(1)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirment was not met as evidenced by:
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Administrator conducted a personal rights training with the Long Term Care Ombudsman on 12/13/23 and 12/14/23.
POC is cleared druing the visit.
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Based on interview and record review, the Licensee did not comply with the section cited above when Staff 1 did not treat R1 with dignity by shoving them, which posed an immediatel personal rights risk to residents in care.
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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 BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
LIC809 (FAS) - (06/04)
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