565850301-12-8-2023-29-AS-ECOZ-CYC25N-20231208160548

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850301
Report Date: 12/08/2023
Date Signed: 12/08/2023 04:06:31 PM

Document Has Been Signed on 12/08/2023 04:06 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VILLARIANA CARE		FACILITY NUMBER:	565850301
ADMINISTRATOR:	BUSCH, HELEN ROSE T.		FACILITY TYPE:	740
ADDRESS:	4731 READING DRIVE		TELEPHONE:	(319) 360-1230
CITY:	OXNARD	STATE: CA	ZIP CODE:	93033
CAPACITY:	6	CENSUS: 5	DATE:	12/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Helen Rose T. Busch		TIME COMPLETED:	04:15 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	At 09:00 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by Administrator Assistant Johnna Udden and informed them of the reason for the visit. Administrator Helen Rose T. Busch arrived shortly. At 09:15 a.m. the LPA conducted a tour of the physical plant with the Administrator to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of four (4) resident bedrooms, one (1) staff room, and three (3) restrooms. The LPA observed one (1) fire extinguishers which was fully charged and last serviced 10/16/2023. At 9:25 a.m. all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. Kitchen: During the facility tour the kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility. Food is prepared based on the menu. Snacks and beverages are always available for the residents. At 9:17 a.m. the LPA observed a pair of scissors inside a drawer of the kitchen island, and a pair of kitchen scissors in the dish drying basket next to the sink. Upon observation, staff locked away both pairs of scissors. Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Report will continue on LIC809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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 12/08/2023 04:06 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLARIANA CARE	FACILITY NUMBER: 565850301
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as mediction for R2 was being administered with the expiration date of 11/2/23, and medications for R1 and R2 were not properly documented which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Administrator agrees to complete a medication audit to ensure all medications are properly documented. Complete audit by 12/15/2023 and informed CCL when audit is complete not later than the POC due date. Licensee also agrees to complete staff medication training.

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as the LPA observed two pair of scissors, hammer, paint, and other items accesible to residents which poses an immediate health and safety risk to persons in care.
	POC Due Date: 12/09/2023
	Plan of Correction
1 2 3 4	Scissors were locked away during the visit and Administrator agrees to install a lock in the garage, by 12/9/23 to ensure that items that could consitute a danger to the residents are inaccesible. Administrator will submit proof to CCL no later than 12/9/23.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/08/2023 04:06 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLARIANA CARE	FACILITY NUMBER: 565850301
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

Resident Records

(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as two residents (R3,R4) were missing the Consent for medical treatment forms LIC627C which poses a potential health and safety risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	Licensee will submit the completed LIC 627C for R3 and R4,to LPA by POC date and will make sure to have all the forms signed by the resident at the time of admission.

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in one resident (R3) as they did not have results for communicable tuberculosis on their medical assesment or on file which poses a potential health, and safety risk to persons in care.
	POC Due Date: 12/22/2023
	Plan of Correction
1 2 3 4	The adminsitrator agreed to the following: 1. Ensure that R3 completes TB testing and provide proof of results to CCL no later than POC due date.

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: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLARIANA CARE	FACILITY NUMBER: 565850301
	VISIT DATE: 12/08/2023

NARRATIVE

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Bathrooms: The LPA observed all bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. At 09:28 a.m. water temperature in residents restroom was measured at 120 degrees Fahrenheit. A conversation was held with the administrator of best practices to ensure water temperature does not exceed 120 degrees Fahrenheit.

Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the living room, which is covered with a screen. The facility maintained a comfortable temperature of 68 degrees. There were no obstructions and/or tripping hazards throughout the facility.

The garage: The LPA observed the garage, where the washer and dryer are held, and the emergency food and water is stored. Cleaning supplies and disinfectants are kept in locked cabinets in the garage. The garage is not locked. At 9:51 a.m. the LPA observed a box labeled “Tools” with an assortment of tools such as pliers and a hammer. The LPA observed power tools, and paint in the garage as well.

Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water on the premises.
Infection Control: The home has an adequate supply of Personal Protection Equipment (PPE) and can obtain additional supplies. The home’s policies and procedures pertaining to infection control were adequate.
Medications: At 10:01 a.m. a medication review was initiated, and the following was observed. Medications are centrally stored and locked in a cabinet in the kitchen inaccessible to residents in care. During Resident #1 (R#1's) audit, the LPA observed Donepezil HCL not properly documented on the centrally stored medication and destruction log, as the expiration date, date filled, and refills did not match the prescription label. During R#2's audit, the LPA observed Levothyroxine not properly documented on the centrally stored medication and destruction log as the strength, date filled, and expiration date did not match the prescription label. During R2’s med audit, the LPA also observed a bottle of Diltiazem CD with the expiration date of 11/2/2023, and observed Quetiapine not properly documented as there was no record of it being administered in the mornings, and per the prescription it should be administered every morning and at bedtime. Upon observation, staff documented the correct information. Report will continue on LIC809-C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLARIANA CARE	FACILITY NUMBER: 565850301
	VISIT DATE: 12/08/2023

NARRATIVE

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Record Review: At 11:20 a.m. a review of facility files was initiated. The LPA reviewed five (5) out of five (5) resident files, and the following was observed. Two out of five residents (R3,R4) do not have Consent for medical treatment forms LIC627C in their files. One out four residents (R3) did not have a Tuberculosis result on file. The LPA reviewed five (5) of five (5) staff files. The LPA reviewed five staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid/CPR cards. All files were complete. The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 11/01/2023). The LPA obtained a Client Roster, Staff Roster, and copy of Insurance liability.

Interviews: The LPA conducted two (2) staff and two (2) resident Interviews. No immediate concerns were voiced.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Administrator Helen Busch.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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