071440415-1-23-2025-15-AS-CFOR-DD82LN-20250123162950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 071440415
Report Date: 01/23/2025
Date Signed: 01/23/2025 04:30:04 PM

Document Has Been Signed on 01/23/2025 04:30 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	VILLA BOARD AND CARE HOME		FACILITY NUMBER:	071440415
ADMINISTRATOR/ DIRECTOR:	VILLA, DANIEL D.		FACILITY TYPE:	740
ADDRESS:	831 CORAL DR.		TELEPHONE:	(510) 799-5572
CITY:	RODEO	STATE: CA	ZIP CODE:	94572
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 0	DATE:	01/23/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:25 PM
MET WITH:	DANIEL VILLA, ADMINISTRATOR		TIME VISIT/ INSPECTION COMPLETED:	04:50 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	On 1/23/2025 at 2:25 PM, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge conducted an unannounced 1-Year Required inspection. LPAs met with Daniel Villa and explained the purpose of the visit. The Administrator currently holds a certificate (#6035480740) waiting on renewal. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPAs toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of three (3) bedrooms not currently occupied by residents, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 73 degrees Fahrenheit. LPAs observed lighting in all rooms are adequate for the comfort and safety of residents. The hot water temperature in the residents’ shared bathroom was measured at 114.4 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was not tagged. Emergency Disaster Plan was posted and updated 1/23/25. First aid kit was observed to be incomplete. LPAs reviewed two (2) staff files which were all complete. Continued on LIC809C.

Bennett Fong	TELEPHONE: (510) -62-2621
Carol Fowler	TELEPHONE: (510) 622-2715
	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VILLA BOARD AND CARE HOME	FACILITY NUMBER: 071440415
	VISIT DATE: 01/23/2025

NARRATIVE

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CONTINUE FROM LIC809C

LPAs requested the following documents to be submitted to CCLD by 1/25/2024.

· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

Infection Control Plan

LPA observed the following deficiencies:

· At 2:45pm, LPA observed clutter such as bags of clothes, bedding under kitchen table and living room.
· At 2:50pm, LPA observed clutter in the back yard air fryer, rice cooker, wood planks, 3 ladders, bedrails, 2 ice chests, fruit picker, wheelchairs, 4 shovels, 2 lamps and an electric saw.
· At 3:00pm, LPA observed a fire extinguisher without a tag or receipt.
· At 3:06pm, LPA observed staff not CPR certified.

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/23/2025 04:30 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VILLA BOARD AND CARE HOME	FACILITY NUMBER: 071440415
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Resident and Support Services

(c) General storage space shall be maintained for equipment and supplies as necessary to ensure that space used to meet other requirements of these regulations is not also used for storage. 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 by having clutters under the kitchen table, in the living room, entry way and back yard such as boxes of clothing, bedding, air fryer, rice cooker, wood planks, 3 ladders, bedrails, 2 ice chests, fruit picker, wheelchairs, 4 shovels, 2 lamps and an electric saw which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/24/2025
	Plan of Correction
1 2 3 4	Administrator agreed to remove all clutter under the kitchen table, in the living room, entry way and back yard such as boxes of clothing, bedding, air fryer, rice cooker, wood planks, 3 ladders, bedrails, 2 ice chests, fruit picker, wheelchairs, 4 shovels, 2 lamps and an electric saw and submit photos to the Department by the POC date.

Section Cited

Telephones

All facilities shall have telephone service on the premises. Facilities with a capacity of sixteen (16) or more persons shall be listed in the telephone directory under the name of the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by not having a landline phone which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/06/2025
	Plan of Correction
1 2 3 4	Administrator agreed to get telephone service at the facility and submit the phone number to the Department by the POC 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.

Bennett Fong	TELEPHONE: (510) -62-2621
Carol Fowler	TELEPHONE: (510) 622-2715
	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 01/23/2025 04:30 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: VILLA BOARD AND CARE HOME	FACILITY NUMBER: 071440415
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/23/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by having Administrator and staff CPR certificates expired which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/07/2025
	Plan of Correction
1 2 3 4	Administrator agreed to update CPR training for all staff and submit a copy to the Department by the POC date

Section Cited

87208((A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7)Sketches, showing dimensions, of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation licensee did not comply with the section cited above by staff/family sleeping in the garage in a makeshift bedroom being used for accommodation. Which poses a potential health and safety risk to residents.
	POC Due Date: 02/14/2025
	Plan of Correction
1 2 3 4	Administrator agreed not to allow staff/family to sleep in the garage. Facility will submit a written addendum to their operating plan describing how the garage will be utilized as intended to CCLD by POC 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.

Bennett Fong	TELEPHONE: (510) -62-2621
Carol Fowler	TELEPHONE: (510) 622-2715
	DATE: 01/23/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2025

LIC809 (FAS) - (06/04)

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