306004459-2-12-2025-22-AS-ARJR-DDTVUK-20250212154453

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306004459
Report Date: 02/12/2025
Date Signed: 02/12/2025 03:44:59 PM

Document Has Been Signed on 02/12/2025 03:44 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 HOMECARE 2		FACILITY NUMBER:	306004459
ADMINISTRATOR/ DIRECTOR:	VILLA DIAZ		FACILITY TYPE:	740
ADDRESS:	811 ST. CLAIR		TELEPHONE:	(714) 760-4693
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY: 6		CENSUS: 4	DATE:	02/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:39 PM
MET WITH:	Arthur Aguas-Caregiver, Juan Diaz-Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:02 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 Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Arthur Aguas. Administrator (AD) Juan Diaz arrived shortly after.

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

LPA observed the Administrator's Certificate for facility AD Juan Diaz which expires on May 24, 2026.

LPA Ramirez 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 two may be on hospice and zero bedridden. There are a total of four bedrooms, of which four 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 were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 109.5-113.5 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. Knives are locked in a kitchen cabinet. 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: 02/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

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

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 HOMECARE 2	FACILITY NUMBER: 306004459
	VISIT DATE: 02/12/2025

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
26
27
28
29
30
31
32

LPA Ramirez observed the emergency disaster and evacuation plan, which is posted by the entrance hallway. LPA observed that the First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care. The medications are locked in a cabinet by the dining room.

For the exterior portion, LPA Ramirez observed patio furniture, and the grounds were free of any hazards. There is one gate in the backyard, which is both self-closing and self-latching. No bodies of water were observed.

LPA reviewed four resident files and three staff files. LPA observed that one of four resident files did not have a pre-admission appraisal; a Deficiency was issued today. LPA interviewed residents and staff present.

For today's visit one deficiency was 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 and Appeal Rights were provided at the time of exit.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3

Document Has Been Signed on 02/12/2025 03:44 PM - It Cannot Be Edited

Created By: Alvaro Ramirez Jr. On 02/12/2025 at 02:49 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 HOMECARE 2	FACILITY NUMBER: 306004459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/12/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87456(a)(2)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, 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 observed that one of four resident records did not have a pre-admission appraisal.
	POC Due Date: 02/13/2025
	Plan of Correction
1 2 3 4	Licensee to complete a pre-admisssion appraisal for Resident 1 (R1) and email POC to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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:

Sheila Santos

LICENSING EVALUATOR NAME:

Alvaro Ramirez Jr.

LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3