306006322-5-17-2024-22-AS-ARJR-D5CUF4-20240517153205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306006322
Report Date: 05/17/2024
Date Signed: 05/17/2024 03:32:10 PM

Document Has Been Signed on 05/17/2024 03:32 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:	PRIME VILLA SKYE		FACILITY NUMBER:	306006322
ADMINISTRATOR/ DIRECTOR:	ATENCIO, JOHN PAUL		FACILITY TYPE:	740
ADDRESS:	3305 DRUID LN		TELEPHONE:	(310) 634-4419
CITY:	ROSSMOOR	STATE: CA	ZIP CODE:	90720
CAPACITY: 6		CENSUS: 5	DATE:	05/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:42 PM
MET WITH:	Samuel Salarza-Caregiver, John Paul Atencio-Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:46 PM

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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 Samuel Salarza. Administrator (AD) John Paul Atencio arrived shortly after.

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

LPA observed the Administrator's Certificate for facility AD John Paul Atencio which expires on December 4, 2025.

LPA Ramirez toured the interior and exterior portions of the facility with caregiver Salarza. The facility is a single level structure and is licensed for six non-ambulatory residents, of which six may be on hospice and one bedridden. Bedroom #4 approved for bedridden. There are a total of four bedrooms, of which four are private 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 four restrooms of which one is for staff and three are 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 109.0-113.1 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: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

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: PRIME VILLA SKYE	FACILITY NUMBER: 306006322
	VISIT DATE: 05/17/2024

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LPA Ramirez observed the emergency disaster and evacuation plan, which is posted by the main entrance. Facility had back-up emergency food and water supply. 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.

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

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

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Atencio.

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: 05/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024

LIC809 (FAS) - (06/04)

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