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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602860
Report Date: 03/23/2023
Date Signed: 03/23/2023 07:04:41 PM

Document Has Been Signed on 03/23/2023 07:04 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:LITTLE VILLAFACILITY NUMBER:
198602860
ADMINISTRATOR:HENG, SANG AFACILITY TYPE:
740
ADDRESS:3040 E. EDDES STREETTELEPHONE:
(213) 910-0442
CITY:WEST COVINASTATE: CAZIP CODE:
91791
CAPACITY: 6CENSUS: 0DATE:
03/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Sang Heng TIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Wong conducted the required annual inspection. LPA arrived unannounced and met with Administrator Sang Heng allowed the entry of the facility. The purpose for the visit was explained. The facility is licensed for AGE RANGE 60 AND OVER. 6 NON-AMBULATORY, OF WHICH 1 IS BEDRIDDEN. HOSPICE WAIVER FOR 3. Facility has fire clearance for 6 non-ambulatory residents, one of which is bedridden. Currently there's no resident reside in the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Infection Control: The facility does not have a infection control plan in file and administrator does not have a health screening report with chest x ray
Operational Requirement: The facility does not have any proof of liability insurance for the facility.
Physical Plant and Environmental Safety: The facility includes family room, dining area, kitchen, living room, three residents rooms and two bathrooms and storage room. The bathrooms are clean, sanitary and in a good working condition. The bathrooms also have grab bars and non-skid mat. LPA checked the hot water in the bathroom and its tested at 67 degrees F. and its below the range of Title 22 regulation. LPA also observed there was all purpose cleaner which are stored on top of the toilet which are not locked.
Staffing: Currently no staff is working at the facility.
Personnel Records-Training: The administrator (Sang Heng) certificate is expired and currently no staff is working at the facility.
Resident Records/Incident Reports: Currently facility has no residents reside
Residents Right Information: LPA did not observe any poster for complaint's information or resident right in the facility
Planned Activities: Currently there's no residents reside in the facility
Food Service: Currently there's no resident reside in the facility.
(See LIC 809C for continuation)





SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE: DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/14/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LITTLE VILLA
FACILITY NUMBER: 198602860
VISIT DATE: 03/23/2023
NARRATIVE
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Incident Medical and Dental: Currently there's no resident reside in the facility and therefore there's no medication in the facility.
Disaster Preparedness: Facility does not have an updated emergency and disaster plan posted in the facility
Residents with Special Health Needs: Currently there's no resident reside in the facility.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8

Exit interview was conducted, Appeals Rights discussed and a copy of the report was given to the Administrator Sang Heng
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 03/23/2023 07:04 PM - It Cannot Be Edited


Created By: Christine Wong On 03/23/2023 at 03:33 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LITTLE VILLA
FACILITY NUMBER: 198602860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA did not observe the administrator has a health screening report with chest x ray which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2023
Plan of Correction
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The administrator will send the copy of the health screening report with chest x ray and send to LPA by 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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 03/23/2023 07:04 PM - It Cannot Be Edited


Created By: Christine Wong On 03/23/2023 at 03:33 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LITTLE VILLA
FACILITY NUMBER: 198602860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the facility never submit the infection control plan or does not have an infection control plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2023
Plan of Correction
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The administrator will submit an infection control plan to LPA by POC due date.
Type B
Section Cited
HSC
1569.605
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA did not observe the copy of recently liability insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2023
Plan of Correction
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The administrator will provide the updated liabiltiy insurance to LPA by 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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 03/23/2023 07:04 PM - It Cannot Be Edited


Created By: Christine Wong On 03/23/2023 at 03:33 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LITTLE VILLA
FACILITY NUMBER: 198602860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observation, LPA observed the Lysol all purpose cleaner on top of the toilet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/25/2023
Plan of Correction
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The administrator will remove the lysol all purpose cleaner right away and locked in the facility and send picture to LPA by POC due date.
Type B
Section Cited
HSC
1569.618(c)(3)
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
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Based on record review, LPA did not observe the CPR and First aid certificate for administrator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2023
Plan of Correction
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The administrator will send the updated CPR and First Aid certificate to LPA by 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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 03/23/2023 07:04 PM - It Cannot Be Edited


Created By: Christine Wong On 03/23/2023 at 03:33 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LITTLE VILLA
FACILITY NUMBER: 198602860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the administrator certfiicate is expired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2023
Plan of Correction
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The administrator will send the updated administrator certfiicate to LPA by POC due date.
Type B
Section Cited
CCR
87468(d)
Personal Rights of Residents
(d) Licensees shall post the personal rights, nondiscrimination notice, and complaint information specified above in English, and, in any other language in which at least five (5) percent of the residents can only read that other language.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the observation, LPA did not observe any poster for personal right or complaint information which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2023
Plan of Correction
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The administrator will post the person right, nondiscrimination notice, complaint information in the facility and send to LPA by 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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 03/23/2023 07:04 PM - It Cannot Be Edited


Created By: Christine Wong On 03/23/2023 at 03:33 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: LITTLE VILLA
FACILITY NUMBER: 198602860

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA did not observe any emergency and disaster plan in the facillity which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/06/2023
Plan of Correction
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The administrator will send the updated emergency and diaster plan in the facility to the LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:David Sicairos
LICENSING EVALUATOR NAME:Christine Wong
LICENSING EVALUATOR SIGNATURE:
DATE: 03/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/23/2023


LIC809 (FAS) - (06/04)
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