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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603439
Report Date: 07/23/2024
Date Signed: 07/23/2024 02:57:15 PM

Document Has Been Signed on 07/23/2024 02:57 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:
07/23/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:39 PM
MET WITH:Care giver Veilma MalitadoTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Plan of Correction (POC) visit to clear deficiencies issued on 7/19/2024 during required annual inspection. LPA Ramirez was greeted by Caregiver Veilma Malitado and explained the purpose of the visit.

The following deficiencies were observed and documented on 7/19/2024 and had a POC date of 7/22/2024:

1. Type A- 87202(a)(1)- FIRE CLEARANCE *immediate $500 civil penalty was assessed 7/19/2024.

2. Type A- 87555(b)(26)- GENERAL FOOD SERVICE REQUIREMENT * $250 for repeat violation in 12-month period was assessed on 7/19/2024.

3. Type A- 87465(h)(2)- INCIDENTAL MEDICAL AND DENTAL CARE SERVICES * $250 for repeat violation in 12-month period was assessed on 7/19/2024.

Licensee did not send POC for violation 87202(a)(1) by 7/22/2024. The licensee sent LPA a copy of a request to increase the number of non-ambulatory residents at the facility. The licensee did apply for this in August of 2023; however, the licensee was not approved by this licensing agency or fire department to operate beyond the facility approved fire clearance. Therefore, LPA Ramirez will issue daily civil penalties for repeat violation of 87202(a)(1) from 7/20/2024 through 7/22/2024, in the amount of $300. Although the licensee did purchase additional nonperishables for six (6) residents for a minimum of 1 week, the licensee did not clear POC by sending proof of retraining of staff on this regulation by POC due date of 7/22/2024.Therefore, LPA Ramirez will issue daily civil penalties for repeat violation of 87555(b)(26) from 7/20/2024 through 7/22/2024, in the amount of $300. Licensee did secure medication that must be refrigerated in lock box; however, licensee did not send proof that staff received retraining by 7/22/2024. Therefore, LPA Ramirez will issue daily civil penalties for repeat violation of 87465(h)(2) from 7/20/2024 through 7/22/2024, in the amount of $300.

Total amount of civil penalties issued today $900.

Exit interview conducted via telephone with Administrator Yenny Indrawati, A 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: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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 3
Document is an Amendment of Original Document on 08/14/2024 02:41 PM


Created By: Kimberly Ramirez On 07/23/2024 at 02:32 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA VICTORIA
FACILITY NUMBER: 198603439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2024
Section Cited
CCR
87202(a)(1

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(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
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Licensee is operating beyond approved fire clearance. Licensee will contact Fire Department and notify regarding fire clearance, and apply and receive approvement of for fire clearance or obatin new medical assessment of residents in question.
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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 was not met as evidence by:
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Licensee will provide LPA Ramirez with contact name, and phone number of fire personnel that was notified regarding fire clearance. Licensee must submit POC via email.

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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:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document is an Amendment of Original Document on 08/14/2024 02:46 PM


Created By: Kimberly Ramirez On 07/23/2024 at 02:40 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA VICTORIA
FACILITY NUMBER: 198603439

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2024
Section Cited
CCR
87555(b)(26)

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(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:
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Licensee will send proof of retraining on this regulation by 7/24/2024 via email.
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Licensee did supply nonperishables but did not send proof of retraining by 7/22/2024.
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Type A
07/24/2024
Section Cited
CCR87465(h)(2)

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(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
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accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Licensee secured medication in fridge but did not send retraining by 7/22/2024.
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Licensee will retrain staff on this regulation by 7/24/2024.
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: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


LIC809 (FAS) - (06/04)
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