<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610011
Report Date: 11/16/2021
Date Signed: 11/16/2021 02:53:31 PM

Document Has Been Signed on 11/16/2021 02:53 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MASCHELLE VILLAFACILITY NUMBER:
197610011
ADMINISTRATOR:MONJE-DU, CHERYFACILITY TYPE:
740
ADDRESS:25577 ALMENDRA DRIVETELEPHONE:
(661) 425-7500
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY: 6CENSUS: 0DATE:
11/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mayen Agcaoili,designeeTIME COMPLETED:
11:50 AM
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
Licensing Program Analyst (LPA) Shira Stamps met with designee, Mayen Agcaoili, for an unannounced one (1) year Required visit for this facility. The facility has not admitted any residence since it has been opened.

Infection control: LPA Stamps reviewed facility mitigation plan (approved on 06/04/21) to make sure the licensee was following the current infection control recommendations. Upon arrival the team was screened by the licensee and asked all infection control questions. LPA were asked to sign-in and sanitize/wash hands.

LPA arrived at 9:45am and contacted the Licensee; who stated the designee was at the facility. LPA was greeted by designee, Mayen Agcaoili. LPA informed the designee of the purpose of the visit.

A tour of the physical plant was conducted with the designee at 10:00am. The facility has four (4) bedrooms and two (2) bathrooms. The facility is Fire Cleared for five(5) non ambulatory, one(1) bedridden.

Resident Rooms
LPA observed each room to have a night stand and sufficient lighting for each resident. LPA tested the exit doors auditory system and it was observed to be operational for each room.

Bathrooms
At 10:05am LPA observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted.

Continued...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MASCHELLE VILLA
FACILITY NUMBER: 197610011
VISIT DATE: 11/16/2021
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
26
27
28
29
30
31
32
Laundry
Chemicals/hazardous items will be in a locked cabinet in the laundry area located in the garage.

Food Inspection
LPA conducted tour at the kitchen around 10:00am observed there to be sufficient stock of two day perishables and seven day non-perishables foods. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to future residents in care.

Physical environment
LPA toured the outside area of the facility at 10:10am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 75°F. The smoke detectors were tested and observed to be operational at 11:00am. There is one(1) fire extinguisher, located in the kitchen. Fire extinguishers were observed to be full. License will provide LPA with service date appointment. Medication and staff files will be located in a locked hallway closet area.LPA observed the garage to be attached to the facility and currently being used for an extra food storage.

Administrative: Annual fee is current.


An exit interview was conducted and a copy of this report was emailed to the Licensee
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2