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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002964
Report Date: 08/16/2024
Date Signed: 08/16/2024 12:00:55 PM

Document Has Been Signed on 08/16/2024 12:00 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JOHN VILLA'S HOME CARE IFACILITY NUMBER:
306002964
ADMINISTRATOR/
DIRECTOR:		VILLA D. DIAZFACILITY TYPE:
740
ADDRESS:219 HANOVERTELEPHONE:
(714) 435-9257
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 6DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Leonor Salazar-Caregiver, Juan Diaz-AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analysts (LPs) Alvaro Ramirez, Jr. and Samer Haddadin conducted an unannounced visit for the Required 1 Year Inspection. LPAs explained the purpose of today’s visit, and were greeted and granted entry by Caregiver Leonor Salazar and Administrator (AD) Juan Diaz.

For today’s visit, LPA observed a total of six residents in care and two staff members on duty.

AD provided proof of payment to show that the certificate is in renewal process. Renewed certificate has not yet been received and is pending. LPA reminded Licensee to post certificate once received.

LPAs toured the interior and exterior portions of the facility with AD Diaz. The facility is a single level structure and is licensed for six non-ambulatory residents, of which four may be on hospice and zero bedridden. There are a total of five bedrooms, of which three are resident bedrooms. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of two restrooms of which one is for staff and one is for residents. Restrooms and toilets were operational, and grab bars and non-skid floor mats were provided. In the staff restroom LPA observed that the sink hot water faucet was off. Per AD the hot water in one of two restrooms was off because the hot water faucet leaks. Water temperature tested 107.7 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located by the kitchen.

CONTINUED ON LIC809-C..

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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 4
Document Has Been Signed on 08/16/2024 12:00 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 08/16/2024 at 11:03 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JOHN VILLA'S HOME CARE I
FACILITY NUMBER: 306002964

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA also observed clutter on the back yard and on the side of the house leading to the exit gate. LPA observed wheelchairs, walkers, tools, two long pieces of wood and cardboard boxes. LPA observed that the trash cans were blocking the exit to the side gate by the garage.
POC Due Date: 08/19/2024
Plan of Correction
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Licensee to email POC proof to LPA by POC due date.
Type A
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 observation, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. In the backyard LPA observed cleaning supplies such as lysol, Fabuloso multi-purpose cleaner, Clorox, and a bottle of paint.
POC Due Date: 08/19/2024
Plan of Correction
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Licensee to email POC proof 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:Sheila Santos
LICENSING EVALUATOR NAME:Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/16/2024 12:00 PM - It Cannot Be Edited


Created By: Alvaro Ramirez Jr. On 08/16/2024 at 11:03 AM
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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JOHN VILLA'S HOME CARE I
FACILITY NUMBER: 306002964

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 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. LPA observed that the sink hot water faucet was off. Per AD the hot water in one of two restrooms was off because the hot water faucet leaks.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee to repair the hot water faucet and email POC to 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:Sheila Santos
LICENSING EVALUATOR NAME:Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: JOHN VILLA'S HOME CARE I
FACILITY NUMBER: 306002964
VISIT DATE: 08/16/2024
NARRATIVE
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LPA Ramirez observed the emergency disaster and evacuation plan, which is posted by the hallway. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA Ramirez observed a shaded area and patio furniture. During the tour LPA also observed clutter on the back yard and on the side of the house leading to the exit gate. There are two gates in the backyard, which both are self-closing and self-latching. No bodies of water were observed.

LPA reviewed six resident files and two staff files. LPA interviewed residents and staff present.

For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Diaz.

A copy of this report was provided at the time of exit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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