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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800490
Report Date: 01/17/2025
Date Signed: 01/17/2025 02:50:13 PM

Document Has Been Signed on 01/17/2025 02:50 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VILLA DESCANSO SENIOR LIVINGFACILITY NUMBER:
331800490
ADMINISTRATOR/
DIRECTOR:		TORRES, GABRIELAFACILITY TYPE:
740
ADDRESS:6683 LEANNE STREETTELEPHONE:
(909) 332-0311
CITY:EASTVALESTATE: CAZIP CODE:
91752
CAPACITY: 6CENSUS: 6DATE:
01/17/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Caregiver- Sandra Sanchez and Valerie RutherfordTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico met with caregivers Sandra Sanchez and Valerie Rutherford to initiate an unannounced case management visit and was granted entry to the facility.

During record review, LPA Rico review staff criminal record clearance. LPA Rico observed S1 did not have a criminal record clearance. In addition, S1 stated they have been working at the facility since 1/10/2025 and do not have their criminal clearance.

During today’s visit the facility a deficiency will be issued, and Civil Penalties were assessed with the amount of $500.00 for S1.

An exit interview was conducted where this report (LIC809), (LIC809D), (LIC421BG) and Appeal Rights were discussed and provided to caregiver Valerie Rutherford.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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 01/17/2025 02:50 PM - It Cannot Be Edited


Created By: Mary Rico On 01/17/2025 at 01:06 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VILLA DESCANSO SENIOR LIVING
FACILITY NUMBER: 331800490

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2025
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance... This requirement is not met as evidenced by:
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Licensee stated to not allow S1 to work at the facility without obtaining the required Criminal background clearance and submit copy of Staff Schedule and Personnel Summary Report (LIC500) to LPA Rico at Plan of Correction due date.
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Based on observation and interview, the Licensee did not comply with the section cited above by not obtaining Staff #1 (S1) criminal record clearance before allowing S1 to work at the facility since 1/10/2025 which pose immediate health, safety and personal rights risk to residents in care.
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POC due date 1/20/2025

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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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2025


LIC809 (FAS) - (06/04)
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