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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850218
Report Date: 12/05/2023
Date Signed: 12/05/2023 11:13:18 AM


Document Has Been Signed on 12/05/2023 11:13 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 IIFACILITY NUMBER:
425850218
ADMINISTRATOR:VILLAROS, JENNIFERFACILITY TYPE:
740
ADDRESS:946 WEST BUNNYTELEPHONE:
(805) 614-4442
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY:6CENSUS: 6DATE:
12/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Luciana Oani, Staff and Jennifer Villaros, Administrator over the phoneTIME COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted an unannounced case management visit to issue deficiencies observed while investigating complaint #29-AS-20230531110058. LPA met with Staff and Administrator over the phone and informed them the reason for the visit.

During the investigation on 6/8/23 LPA Chavez went to the facility for the unannounced initial visit and was greeted by Staff 1 (S1) and Resident 2 (R2). LPA Chavez observed S1 tell R2 to “get back and go away.” LPA interviewed R2 at 1:31pm who stated they do not like S1 because they are mean to R2. At 1:45pm LPA observed Resident 3 (R3) stand up and R2 stated “do you want to see who she [LPA] is?” S1 went over to residents and R2 stated “ you won’t even let [R3] see who she is, you’re a mean lady. Do you know you’re a mean lady?”. S1 responded, yes I’m a mean lady.” Interview with Administrator and Licensee revealed that R1 had a psychotic breakdown and was admitted to a mental institution on 6/5/23. R1 was bolting out the door and staff tried to get R1 back in the house, and grabbed R1’s arm to get R1 back. Administrator stated that R1 told them Staff 2 (S2) was mean to R1. Administrator explained there was tension between them because R1 wanted their medication earlier then prescribed and S2 wouldn’t give them to R1. Additional interviews with residents revealed the main staff member S3 is a great caregiver and had no issues with the, but multiple residents stated Staff 4 (S4) is constantly rude to staff and residents. Based on the observation and interviews, residents were not treated with dignity by staff during verbal interactions and when they grabbed R1’s arm.

Exit interview, deficiencies issued on 809-D, report given, appeal rights given.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
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 12/05/2023 11:13 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 II
FACILITY NUMBER: 425850218

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/05/2023
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...This requirement was not met as
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Administrator agreed to schedule a personal rights training with all staff and submit the scheduled training date to CCL by 12/6/23. Administrator agreed to send training records to CCL by 12/15/23.
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evidenced by: Based on interviews, the licensee did not comply with the section cited above when staff did not speak to residents with dignity, which posed an immediate health and safety risk to persons 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: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
LIC809 (FAS) - (06/04)
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