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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603439
Report Date: 07/19/2024
Date Signed: 07/19/2024 05:28:50 PM

Document Has Been Signed on 07/19/2024 05:28 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:
07/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:13 AM
MET WITH:Caregiver Jermin PattiradjawaneTIME VISIT/
INSPECTION COMPLETED:
05:35 PM
NARRATIVE
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This facility is licensed to serve three (3) non-ambulatory and 3 (3) ambulatory residents over the age of 60. Bedroom#1 may retain two (2) non-ambulatory residents and bedroom#5 may retain one (1) non-ambulatory resident. This facility may retain no more than five (05) hospice residents. There are three (03) residents under hospice care. The facility is a single-story dwelling located in a residential neighborhood. Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection. LPA Ramirez met with Caregiver Jermin Pattiradjawane and explained the purpose of today’s visit.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected six (6) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets. LPA Ramirez observed the following deficiencies: Smell of urine omitting from resident bedroom #5, blinds missing and broken in resident bedroom#5, resident bedroom#5 screens were observed to have dust debris all over the screen, broken and discarded fridge in backyard, bubbling, peeling and yellow-brown on ceiling in living room area, and facility dryer was observed to be in disrepair. LPA Ramirez will issue Type B deficiencies.

SEE 809-C.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE: DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/19/2024
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 9
Document Has Been Signed on 07/19/2024 05:28 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/19/2024 at 12:59 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: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(1)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (1) Nonambulatory persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, 4 out of the 6 residents are nonambulatory, facility may only retain 3 nonambulatory, the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2024
Plan of Correction
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Licensee will contact Fire department for new fire clearance or submit new medical assessment for residents and send proof to LPA Ramirez by POC date.
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA Ramirez observed 7 previously opened bags sandwich bread and 1 bag cookies, that smelled rancid, the licensee did not comply with the section cited above in 6 out of 6 residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2024
Plan of Correction
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Staff removed rancid food during inspection. Licensee will retrain staff on this regulation and send proof to LPA Ramirez by 8/2/2024. Proof must be submitted via email.
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:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 07/19/2024 05:28 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/19/2024 at 12:59 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: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, minimum of one week or nonperishable food for 6 residents was not observed, the licensee did not comply with the section cited above in 6 out of 6 residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2024
Plan of Correction
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Licensee will purchase nonperishables for a minimum of one week for 6 residents and will retrain staff on this regulation by 7/22/2024. LPA Ramirez will return to clear deficiency.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, 2 out of the 6 residents had medication stored in the fridge that was accessible to residents and visitors, the licensee did not comply with the section cited above in 6 out of 6 residents and visitors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2024
Plan of Correction
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LIcensee will secure medications that must be refrigerated and retrain staff on this regulation. Licensee will submit proof via email.
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:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 07/19/2024 05:28 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/19/2024 at 12:59 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: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Smell of urine omitting from #5, Blinds missing and broken in room#5, Broken and disgarded fridge in backyard, Bubbling, peeling and yellow-brown on ceiling in livingroom area the licensee did not comply with the section cited above in 6 out of 6 residents, staff and/or visitors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will clean and disinfect room# 5, replace or replair window blinds in room#5, remove dicarded fridge from backyard, repair ceiling in livingroom area by 8/2/2024. LPA Ramirez will return to clear deficiency.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, room#5 window screens were observed to contain dust debris, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will clean screens and keep them clean by 8/2/2024. Licensee will retrain staff on this regulation. Proof of retraining must be submitted by 8/2/2024. LPA Ramirez will return to clear deficiency.
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:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 07/19/2024 05:28 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/19/2024 at 12:59 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: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(g)(1)
Maintenance and Operation
(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 noise shall not reach resident or employee areas.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, facility dryer has been in disrepair for months, the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will repair or place dryer ny 7/26/2024. LPA Ramirez will return to clear deficiency.
Type B
Section Cited
CCR
87555(b)(21)
General Food Service Requirements
(b) The following food service requirements shall apply: (21) Freezers of adequate size shall be maintained at a temperature of 0 degree F (-17.7 degree C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degree F. (4 degree C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, freezer and fridge were observed to contain dead insects, hair and food debris on the floor of fridge and freezer the licensee did not comply with the section cited above in 6 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will clean facility fridge and freezer. LPA Ramirez will return to clear deficiency.
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:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 07/19/2024 05:28 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/19/2024 at 12:59 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: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, live and dead insects were observed in kitchen cabinets, the licensee did not comply with the section cited above in 6 out of 6 residents, staff and/or visitors which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will submit pest control services plan by 8/2/2024 and submit via email to LPA Ramirez.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, R1's last medical assessment in R1's file was dated 2019, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will obtain new medical assessment for R1 and retrain staff on this regulation by 8/2/2024. Proof must be submitted via email.
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:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


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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: VILLA VICTORIA
FACILITY NUMBER: 198603439
VISIT DATE: 07/19/2024
NARRATIVE
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Food Service: LPA Ramirez did not observe sufficient supply of nonperishable for one week. LPA Ramirez counted between 10 to 20 cans of canned food. Seven (7) out of the twenty (20) canned good had best by dates of 2020, 2021, 2022, and 2023. LPA Ramirez observed two (2) out of the twenty (20) canned good to contain best by dates of July 11, 2024. LPA Ramirez observed five (5) unopened bags of chips with guaranteed fresh until dates of Jan 2024 and May 2024. LPA Ramirez observed one (1) half full tub of animal cracker cookies with a best by date of May 2024. LPA Ramirez observed one (1) unopen can of cookies with a best by date of June 7, 2024. LPA Ramirez observed two (2) unopened bags of popcorn with guaranteed fresh dates of Feb 2024. LPA Ramirez did observe perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Freezer was observed to have dead insects suck to bottom of freezer floor. Refrigerator floor contained dead insects and hair strands. LPA Ramirez observed several bags of sandwich bread to smell rancid and could smell it through the bag. Some bags of bread were open and per staff interviews, residents were being served this bread. 2 insect eggs fell out of a bag of bread that was semi open when LPA inspected the bread. LPA Ramirez will issue Type A & Type B deficiencies based these on observation.

Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed a facility land line.

Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D) in place. Present staff could not locate drills or recall drill being conducted in the last three months. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility.



Residents with Special Needs: No large bodies of water were observed. LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Resident#1 (R1) did not have a current medical assessment on file. LPA Ramirez will issue Type B deficiency based on observation.

See 809-C.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
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Page: 7 of 9
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: VILLA VICTORIA
FACILITY NUMBER: 198603439
VISIT DATE: 07/19/2024
NARRATIVE
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Health Related Services/Incidental Medical Services: Medications are centrally stored in the kitchen cabinet and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. LPA Ramirez observed two (2) residents’ medications in the facility refrigerator to be accessible. LPA Ramirez will issue Type A deficiency based on observation.

Staffing: Administrator Certificate for Yenny Indrawati and it expires 02/17/2025. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility.

Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for two (2) out of the two (2) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for two (2) out of the two (2) personnel records reviewed.

Infection Control: Staff are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place.


Operational Requirements: This facility is licensed to serve three (3) non-ambulatory and 3 (3) ambulatory residents over the age of 60. Bedroom#1 may retain two (2) non-ambulatory residents and bedroom#5 may retain one (1) non-ambulatory resident. This facility may retain no more than five (05) hospice residents. There are three (03) residents under hospice care. Four (4) out of the six (6) residents are nonambulatory. The facility may only retain 3 nonambulatory residents. LPA Ramirez will issue Type A and Type B deficiency and an immediate civil penalty based on these observations.

Resident Records/Incident Reports: LPA reviewed resident files for six (6) residents. Resident files are maintained at the facility.

Eleven (11) deficiencies were cited today, six (6) civil penalty violations in the amount of $250 for each violation, for repeat offenses and one (1) immediate civil penalty for $500. Total amount of civil penalties and immediate civil penalties are $2,000. Exit interview was conducted and copy of this report, 809-D, LIC 421IM, LIC 421FC and appeals rights was provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 07/19/2024 05:28 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 07/19/2024 at 04:12 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: 07/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(8)
87705 Care of Persons with Dementia
(8) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, present staff could not locate drills or recall drill being conducted in the last three months, the licensee did not comply with the section cited above in 1 out of 6 residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2024
Plan of Correction
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Licensee will retrain staff on this regulation and conduct and document drill. Proof must be submitted via email.
Section Cited
Deficient Practice Statement
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3
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POC Due Date:
Plan of Correction
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4
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:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024


LIC809 (FAS) - (06/04)
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