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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610011
Report Date: 10/20/2022
Date Signed: 10/20/2022 01:39:24 PM

Document Has Been Signed on 10/20/2022 01:39 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: DATE:
10/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lebora Nakahara, LicenseeTIME COMPLETED:
02:10 PM
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At 09:00am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by Staff #1 (S1), who granted access to the facility. The Administrator arrived shortly after and LPA explained the reason for the visit.

At 9:15am, LPA conducted a tour of the facility and the following was observed:

Infection control: Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. LPA observed all trash cans throughout the facility have fitted lids.

Kitchen: At approximately, 09:25am LPA toured the kitchen area and did observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. LPA observed a fire extinguisher in the kitchen and it was last serviced on 11/17//21.

Medications: At approximately, 09:45am LPA observed medications are centrally stored and locked in the closet, by the kitchen area and inaccessible to residents in care.



Bedrooms: There are four (4) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational.

Bathrooms: At 10:00am LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 111.0°F. LPA observed


Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022
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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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: 10/20/2022
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appropriate grab bar and non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Common Areas: The facility maintains a comfortable temperature at 72°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 10:20am they were tested and observed to be operational.


Outside areas: At approximately, 10:30am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

The garage: Laundry area is located in an attached garage and kept locked and inaccessible to residents.

Administrative: LPA collected Certificate of Liability Insurance and LIC.500.


Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency is cited (refer to LIC 809-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/20/2022 01:39 PM - It Cannot Be Edited


Created By: Angela Panushkina On 10/20/2022 at 12:28 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MASCHELLE VILLA
FACILITY NUMBER: 197610011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/21/2022
Section Cited

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified...
This requirement is not met as evidenced by:
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Based on record review, the licensee did not comply with the section cited above. S1 and S2 were not associated to the facility which poses an immediate health, safety risk to persons in care.
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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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Angela Panushkina
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2022


LIC809 (FAS) - (06/04)
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