<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004459
Report Date: 04/13/2022
Date Signed: 04/13/2022 03:58:19 PM

Document Has Been Signed on 04/13/2022 03:58 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JOHN VILLA'S HOMECARE 2FACILITY NUMBER:
306004459
ADMINISTRATOR:VILLA DIAZFACILITY TYPE:
740
ADDRESS:811 ST. CLAIRTELEPHONE:
(714) 760-4693
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 5DATE:
04/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Villa DiazTIME COMPLETED:
04:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPAs) Jessica Cho, Joseph Alejandre, and Celine DePerio made an unannounced visit to conduct the required annual inspection (mitigation). LPAs were greeted and granted entry by Administer (AD) Villa Diaz after completing the Coronavirus 2019 (COVID-19) screening procedures. LPAs stated the purpose of this visit. The facility is a single level structure and licensed for six non-ambulatory residents of which 2 has hospice waivers. For this visit, there are five residents in care and two staff members on duty. LPAs toured the interior portion of the facility. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke detectors, carbon monoxide, and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with hand rails, required paper towels, and soap. Facility met the minimum two day perishable and seven day non-perishable food stock requirements. Medications, cleaning supplies, and sharp items were inaccessible to residents in care. LPAs inspected the First Aid Kit and had all the required elements. The fire extinguishers were mounted and charged. For the exterior portion, the backyard at this time is off limits to residents because of work being done. LPA discussed Assembly Bill 665 that requires a licensee of any adult or senior care residential facility that has internet service to provide at least one internet access device, such as a computer, smart phone, tablet or other device, that: can support real-time interactive applications; is equipped with video conferencing technology, including microphone and camera functions; and is dedicated for client or resident use. LPAs observed a laptop in the living room. LPAs reviewed the COVID-19 mitigation plan of the facility.

For this visit, there are no deficiencies cited as per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with the AD and copy was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Jessica Cho
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2022
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 1