565850506-7-10-2025-29-AS-ECOZ-DJFRVH-20250710132133

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850506
Report Date: 07/10/2025
Date Signed: 07/10/2025 01:22:32 PM

Document Has Been Signed on 07/10/2025 01:22 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 II		FACILITY NUMBER:	565850506
ADMINISTRATOR/ DIRECTOR:	BUSCH, HELEN ROSE T.		FACILITY TYPE:	740
ADDRESS:	1021 NIGHTINGLE PLACE		TELEPHONE:	(319) 360-1230
CITY:	OXNARD	STATE: CA	ZIP CODE:	93036
CAPACITY: 6		CENSUS: 6	DATE:	07/10/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Johnna Macanin-Co Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:30 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 09:35 a.m. Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit. The LPA met with C0-Administrator Johnna Macanin and informed them of the reason for the visit. At 09:45 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 two (2) private bedrooms and two (2) shared bedrooms. Bedroom #2 has direct access outside. The LPA observed fire extinguishers which were fully charged and purchased on 05/17/2025. 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. Kitchen: The facility has at least seven (7) day supply of non-perishable food and two (2) days perishable food. Appliances and all equipment appear to be clean and in good repair. Kitchen knives, sharps, and cleaning supplies were observed in locked cabinet. Bedrooms: Each bedroom is equipped with clean mattresses, pillows, and bedding. There is a closet in the hallway with a sufficient supply of linens, including blankets, bath towels and wash cloths. Bedrooms have sufficient lighting. Bathrooms: There is two common restrooms in the hallway and one private restroom in bedroom #2.The LPA observed bathrooms, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. At 09:58 a.m. water temperature in the private restroom was measured at 111.2 degrees Fahrenheit and at 115.2 degrees Fahrenheit in one of the common bathrooms. Report will continue on LIC9099-C, 2nd page.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 II	FACILITY NUMBER: 565850506
	VISIT DATE: 07/10/2025

NARRATIVE

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Common Areas: The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. A working telephone is present. There are activity supplies in the living rooms. All doors have functioning auditory alarms when opened. At 10:15 a.m. the LPA observed the Administrator administered medication to a resident by feeding it to them via a spoon.
The garage/Laundry room: The laundry room holds the washer, dryer and detergent and was observed locked and inaccessible to the residents in care. The garage is accessible from the house; the doors were locked from the inside of the house. Toxic or danger items or tools in the garage, were locked in a cabinet during the visit. Emergency food and water is stored in the garage.
Surrounding Grounds (Outdoors): The exterior passageways were clean and clear of any obstructions. There is a covered patio area with outdoor seating. The entire property is fenced. The back and sides of the house are separated from the front yard by a gate and fence
Record Review: At 11:10 a.m. a review of facility files was initiated. The LPA reviewed five (5) out of six (6) resident files. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. All records were in order. The LPA reviewed five (5) out of seven (7) Personnel files. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. Facility records are stored in the locked closet in the living room. The LPA observed documentation of Infection Control, Disaster prevention and last Disaster drill (conducted on 05/01/2025). The LPA obtained Client Roster, Staff Roster and Insurance liability.
Medication Audit: At 12:00 p.m. the LPA conducted Medications audit for two (2) residents. The medications are locked in a locked closet in the living room. Medications are labeled and checked for expiration dates. Medications are documented on the centrally stored medications and destruction record. During Resident 1's (R1's) audit the LPA observed an under count of Acetaminophen by one (1) pill based on the start date and quantity. Upon observation, the Administrator called the staff responsible for the medications and they stated they wrote the wrong start date in error.
Interviews: The LPA conducted two (2) resident and two (2) staff Interviews. No immediate concerns were voiced by the residents. Staff interviews revealed that medications are not self-administered at times and staff put the medications into the resident's mouth.

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 the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/10/2025 01:22 PM - It Cannot Be Edited

Created By: Esther Cortez On 07/10/2025 at 12:59 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: VILLARIANA CARE II	FACILITY NUMBER: 565850506
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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 observation, interview,record review, the licensee did not comply with the section cited above as LPA observed the Administrator feed a resident medication with a spoon, staff interviews revealed residents sometimes do not self-administer medications, and there was an undercount in one of R1's medications during the medication audit which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/24/2025
	Plan of Correction
1 2 3 4	Administrator agreed to have staff assist all residents with self-administration of medications and have have staff including Administrator's obtain medication training from a third-party and submit proof of training to licensing by due date of 07/24/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:

	Esther Cortez
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025

LIC809 (FAS) - (06/04)

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