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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802416
Report Date: 11/30/2022
Date Signed: 12/01/2022 09:04:19 AM


Document Has Been Signed on 12/01/2022 09:04 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 TERESA RESIDENTIAL CAREFACILITY NUMBER:
565802416
ADMINISTRATOR:MARILOU ROJASFACILITY TYPE:
740
ADDRESS:821 TERESA STREETTELEPHONE:
(805) 604-7772
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY:6CENSUS: 6DATE:
11/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:23 AM
MET WITH:Marilou RojasTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 11:23 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA initially met with caregiver Emerson Del Monte who was not associated to the facility but has worked at the facility for one year. Co-Administrator Victor Hernandez arrived at approximately 11:40 and Administrator Marilou Rojas arrived at approximately noon. LPA explained the reason for the visit to all parties. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher appeared fully charged and was last inspected on 1/20/2022. KITCHEN: Caregivers were preparing lunch so some locks on cabinets were open. LPA observed knives are stored in a locked drawer and chemicals are stored in a locked cabinet under the sink. Kitchen appliances appeared to be in operable condition. The facility had a sufficient supply of perishable and non-perishable food. BEDROOMS: The LPA observed two double-occupancy bedrooms and two single-occupancy bedrooms, appropriately furnished. RESTROOMS: Restrooms are clean and sanitary and in operating condition. COMMON SPACES: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The LPA observed the required postings throughout the facility. The backyard patio is equipped with furniture for clients' use. The garage and staff room were locked. Medication is stored in a locked cabinet in the hall/desk area. INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and can obtain additional supplies as needed. The facility has appropriate plans in place in the event clients and/or staff show symptoms of or test positive for COVID.

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. Report and appeal rights emailed to administrator.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
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 12/01/2022 09:04 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 TERESA RESIDENTIAL CARE
FACILITY NUMBER: 565802416

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)(f)
Criminal Record Clearance. Prior to working ... all individuals subject to a criminal record review shall request a transfer... Violation ... shall result in an immediate ... penalties of one hundred dollars ($100) per day for a maximum of five (5) days by the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and interview, the licensee failed to ensure that all employees are associated to the facility, as Emerson DelMonte was not associated to the facility. This poses an immediate health and safety risk to residents in care. This violation resulted in a $500 civil penalty assessment.
POC Due Date: 11/30/2022
Plan of Correction
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The Administrator has agreed to the following:
Associate the individual to the facility. The paperwork was provided at the time of the visit. This was cleared the day of the visit, deficiency is cleared.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2022
LIC809 (FAS) - (06/04)
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