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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603439
Report Date: 08/25/2023
Date Signed: 08/25/2023 04:07:06 PM

Document Has Been Signed on 08/25/2023 04:07 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:VILLA VICTORIAFACILITY NUMBER:
198603439
ADMINISTRATOR:INDRAWATI, YENNYFACILITY TYPE:
740
ADDRESS:1640 S. GLENDORA AVETELEPHONE:
(626) 888-7811
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 6DATE:
08/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:02 PM
MET WITH:Yenny Idrawati, Administrator TIME COMPLETED:
04:16 PM
NARRATIVE
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LPAs Alberto Lopez and Sanjay Vaid made unannounced visit to for POC verification. LPAs met with staff Jermin Hendriette and spoke with administrator via phone and explained purpose of the visit.

Administrator was able to clear most deficiencies except two. One the deficiencies( 87458 (a) to update LIC 602, administrator asked for 1 week extension and LPA gave unitl September 7 2023 for that to be complete.

On the disrepair deficiency 87303(a) to repair or replace dryer, LPA cited and provided 5 days until August 30th to be in compliance with either repairing or replacing dryer.

Civil penalties accessed 100 per day x 10 days on prior deficiency.

LPA conducted interview and staff signed on behalf of Administrator with her prior consent.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2023
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
Document Has Been Signed on 08/25/2023 04:07 PM - It Cannot Be Edited


Created By: Alberto Lopez On 08/25/2023 at 03:23 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: VILLA VICTORIA
FACILITY NUMBER: 198603439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/30/2023
Section Cited
CCR
87303(g)(1)

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(g) Facilities which have machines and do their own laundry shall:

(1) Have adequate supplies available and equipment maintained in good repair. Space used to sort soiled linen shall be separate from the clean linen storage and handling area. Except for facilities licensed for fifteen (15) residents or less, the space used to do laundry shall not be part of an area used for storage of anything other than clean linens and/or other supplies normally associated with laundry activities. Steam, odors, lint and objectionable laundry noises shall not reach resident or employee areas.

This requirement is not met as evidenced by

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Administrator will repair or replace dryer by POC date and send proof to LPA.
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Based on interviews, records review and observation, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. The facility currently has 1 dryers that is not working.
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HSC


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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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023


LIC809 (FAS) - (06/04)
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