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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603439
Report Date: 04/18/2024
Date Signed: 04/18/2024 03:54:01 PM

Document Has Been Signed on 04/18/2024 03:54 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/
DIRECTOR:		INDRAWATI, YENNYFACILITY TYPE:
740
ADDRESS:1640 S. GLENDORA AVETELEPHONE:
(626) 888-7811
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY: 6CENSUS: 6DATE:
04/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Henny Patiradjawane, StaffTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit. The reason was explained to staff.

During a complaint investigation today for #28-AS-20240410124456, LPA observed a resident who is using oxygen. LPA smelled cigarette smoke coming from inside the facility. Once bedroom #4's door was opened, the room was filled with cigarette smell. Staff accompanying LPA acknowledged that the resident often smokes inside the room while in bed. Staff also revealed that resident in bedroom #5 also smokes in the room and not outside. Staff interviewed stated the residents do not comply and smoke indoor.

A deficiency was issued on the LIC809D. A copy of this report and appeal rights were given to the staff.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024
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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Document Has Been Signed on 04/18/2024 03:54 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 04/18/2024 at 03:10 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: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2024
Section Cited
CCR
87618(b)(3)(C)

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87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611 (3) Ensuring that the use of oxygen equipment...(C) Smoking shall be prohibited where oxygen is in use.
This requirement is not met as evidenced by:
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The licensee shall conduct a staff in-service training to ensure that residents are smoking only in designated areas. The POC is due 4/19/24.
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Based on observation, the licensee did not ensure that residents are not smoking inside the facility which poses an immediate health, safety, and personal rights risk to residents 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:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2024


LIC809 (FAS) - (06/04)
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