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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306002964
Report Date: 01/22/2025
Date Signed: 01/22/2025 04:41:17 PM

Document Has Been Signed on 01/22/2025 04:41 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:
01/22/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:31 PM
MET WITH:Juan & Villa DiazTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Lydia Martinez conducted this Case Management visit in conjunction with a Complaint Control Number 22-AS-20250115125037.

LPA Martinez toured facility and observed clutter in the back yard and on both side walkways of the house leading to the exit gates. LPA observed 10 huge truck tires on one side and bags, boxes, tools, ladder, kids toys, fans, 2 propane tanks, 3 oxygen tanks, wheelbarrow, empty plastic bins, and trash cans on the other side and in front of the shed.

Based on the observations made during today’s visit, deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with Administrators and a copy was sent to email on file.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 01/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/22/2025
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 01/22/2025 04:41 PM - It Cannot Be Edited


Created By: Lydia Martinez On 01/22/2025 at 01:46 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
, 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: 01/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2025
Section Cited
CCR
87303(a)

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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:
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Licensee to ensure the facility is clean, safe, sanitary and in good repair at all times. Licensee to clear back yard of clutter and clear walkway on both side leading to exits and submit proof of correction to LPA by 01/31/2025..
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LPA observed clutter in the back yard and on both sides of the house leading to the exit gates; 10 huge tires on one side and bags, boxes, tools, ladder, kids toys, fans, 2 propane tanks, 3 oxygen tanks, wheelbarrow, empty plastic bins, and trash cans on the other side and in front of the shed.
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Since this a second violation within 12 months, an LIC 421 Civil penalty was assessed today in the amount of $250.00 for the repeat violation.

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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:Lourdes Montoya
LICENSING EVALUATOR NAME:Lydia Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2025


LIC809 (FAS) - (06/04)
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