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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802416
Report Date: 10/07/2022
Date Signed: 10/07/2022 05:38:47 PM


Document Has Been Signed on 10/07/2022 05:38 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 TERESA RESIDENTIAL CAREFACILITY NUMBER:
565802416
ADMINISTRATOR:VICTOR HERNANDEZFACILITY TYPE:
740
ADDRESS:821 TERESA STREETTELEPHONE:
(805) 604-7772
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:6CENSUS: 5DATE:
10/07/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Victor HernandezTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst ( LPA) Angel Ascencio conducted a Case Management visit to the above facility. LPA met with Administrator Victor Hernandez at 2:00 p.m.

During facility tour at 1:42 p.m., LPA Ascencio observed an unlocked room that contained Antacid Tablets, Centrum Vitamins, Colgate, Tylenonl, Tamsulosin 0.4 mg accessible to residents in care. Staff stated it is a staff room. LPA observed staff lock the staff room. At 1:44 pm, LPA observed Calmoseptine ointment in Room #4 accessible to resident in care. Staff stated it was left there when they change. Staff placed item in an inaccessible location. At 1:47 p.m., LPA observed Voltaren Arthritis Pain rub, Ensueno Laundry detergent, colgate toothpaste, Clorox, and dove shampoo in an unlocked garage door. Staff stated they were doing laundry. Staff proceeded to lock the garage door. At 1:51 pm, LPA Ascencio observed Hydrocortizone 1%, DM Max relief Cough Suppressant, Long Acting Tussin, Omeprazole, and Ibuprofen in an unlocked cabinet. Staff proceeded to lock the drawer.


Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):


Exit interview conducted, today's reports, civil penalty and appeal rights were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
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 10/07/2022 05:38 PM - 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 TERESA RESIDENTIAL CARE
FACILITY NUMBER: 565802416

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2022
Section Cited

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87705 Care of Persons with Dementia (f)(2) (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by:
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as LPA observed over-the-counter medication, cleaning supplies and disinfectants accessible to residents which poses an immediate health, safety and personal rights 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel AscencioTELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2