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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006204
Report Date: 11/06/2024
Date Signed: 11/06/2024 05:02:04 PM

Document Has Been Signed on 11/06/2024 05:02 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:WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVINGFACILITY NUMBER:
306006204
ADMINISTRATOR/
DIRECTOR:		ESPINAL, ALMAFACILITY TYPE:
740
ADDRESS:2025 N BUSH STTELEPHONE:
(714) 541-3357
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY: 130CENSUS: 78DATE:
11/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Alma EspinalTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
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Licensing Program Analysts (LPAs) Kimberly Lyman and William Vanegas conducted an unannounced visit to Willow View Gardens. The purpose of today’s visit was to conduct the annual required inspection. LPAs were allowed entry into the facility and explained the reason for the visit.. Facility is licensed for 130 non-ambulatory residents of which 50 may be bedridden.. Facility has an approved hospice waiver for 50 residents and the facility has 59 residents in assisted living and 19 in memory care. There are 10 residents on hospice. Administrator Alma Espinal has an administrator certificate expiring on 04/01/2026. LPAs Lyman and Vanegas along with Administrator toured the facility at 8:48 AM. LPAs toured the physical plant, checked food service, and the first aid kit. The facility consists of two stories including a library, bistro, cinema room and hair salon.. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. At 9:15 AM, LPAs observed unsecured medications and supplements in Resident 6's apartment. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. Water temperature measured between 105.4 degrees F and 108.3 degrees F in all restrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPAs toured the main level medication room and observed medications are unsecured and accessible to residents in care. Common areas were clean and clear of hazards, doorways were free of obstructions. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances are operational during today's visit. Toxins are secured in a closet. Smoke detectors and carbon monoxide detectors are tested in-house bi-monthly and fire/ sprinkler inspections are conducted by a third party, Hilltop Alarms. Fire extinguishers were fully charged. LPAs reviewed the infection control plan and emergency disaster plans and plans are complete. Facility conducts monthly emergency drills with the last drill conducted on 10/14/2024. LPAs observed ample emergency food and water. Outside grounds were toured. LPAs observed multiple outside patio areas including a smoking area. There is ample outdoor shaded seating for residents.. Walkways around the facility were clear of hazards. There are no security bars or weapons on the premises. continued ON LIC 809C DATED 11/06/2024
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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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: WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVING
FACILITY NUMBER: 306006204
VISIT DATE: 11/06/2024
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First aid kit contained all required items including tweezers, scissors and thermometer.Facility provides activities in the form of music, art and puzzles. LPAs reviewed eight resident files and six staff files. All resident files contained required documentation including admission agreements, physician reports, resident appraisals, and physician orders for bed rails as indicated. Staff files reviewed contained required documentation including required annual training, medical assessment, criminal record clearance and proof of CPR training. At 1:15 PM, LPAs observed three out of three staff do not have proof of TB testing in the file. At 3:00 PM, LPAs reviewed medication storage and administration. LPAs observed four out seven medications reviewed are not being administered per physician order or are lacking documentation. Medications are stored in locked medication carts,


Based on the observations made during today’s visit, deficiencies are being cited per Title 22 Division 6 the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 11/06/2024 05:02 PM - It Cannot Be Edited


Created By: William Vanegas On 11/06/2024 at 04:10 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: WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVING
FACILITY NUMBER: 306006204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of six personel records not consisting of a TB test result which poses a potential health and saftey risk to persons in care.
POC Due Date: 11/20/2024
Plan of Correction
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Licensee is to obtain copies of TB test results for each of the identified staff. Licensee is to forward proff of TB test results 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:Armando J Lucero
LICENSING EVALUATOR NAME:William Vanegas
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/06/2024 05:02 PM - It Cannot Be Edited


Created By: William Vanegas On 11/06/2024 at 04:19 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: WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVING
FACILITY NUMBER: 306006204

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
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 immidiate health and saftey reisk to residence in care. LPA's observed multiple instances of unsecured medications.
POC Due Date: 11/07/2024
Plan of Correction
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Licensee will secure medications and forward proof to LPA by POC due date.
Type A
Section Cited
CCR
87464(f)(4)
Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports.

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 in four out of seven resident medications not being administered per physician's order. Which poses an immediate health and safety risk to persons in care.
POC Due Date: 11/07/2024
Plan of Correction
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Licensee to provide an inservice on medication administration and provide 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:Armando J Lucero
LICENSING EVALUATOR NAME:William Vanegas
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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