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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880693
Report Date: 07/21/2022
Date Signed: 07/21/2022 01:59:40 PM

Document Has Been Signed on 07/21/2022 01:59 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:ST FRANCIS VILLAFACILITY NUMBER:
331880693
ADMINISTRATOR:DANG, ANHTUANFACILITY TYPE:
740
ADDRESS:23571 RHEA DRTELEPHONE:
(714) 306-3259
CITY:MORENO VALLEYSTATE: CAZIP CODE:
92553
CAPACITY: 6CENSUS: 2DATE:
07/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Anhtuan Dang, AdministratorTIME COMPLETED:
02:10 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to conduct an annual inspection, with emphasis on infection control. LPA was greeted by Caretaker Dominator Ragojos, and explained the purpose of today's visit. Administrator Anhtuan Dang was inside the facility at time of visit. There was 1 client inside the facility, with 1 client at their day program.

During today’s visit, LPA toured the facility and made observations pertaining to the facility’s infection control measures. LPA observed proper signage throughout the facility, sufficient hand hygiene supplies, and sufficient cleaning and disinfecting provisions also 30 days supply of Personal Protective Equipment (PPE).

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19. When and how to isolate/quarantine clients, and when to schedule cleaning and disinfection times of high traffic and frequently touched areas.

The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the client's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illness.

Continued on LIC809-C.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2022
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 07/21/2022 01:59 PM - It Cannot Be Edited


Created By: Jesse Gardner On 07/21/2022 at 01:29 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: ST FRANCIS VILLA
FACILITY NUMBER: 331880693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(b)(2)
87303 Maintenance and Operation: (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range between 78, and 85 degrees, or in areas of extreme heat to 30 degrees less than the outside temperature.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation of the inside thermostat reaching 88 degrees with an outside temperature averaging 95 degrees, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/28/2022
Plan of Correction
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Licensee states that they will adhere to the regulation, and will self-certify that regulation is understood by sending LPA an email that is signed by all staff that the regulation is understood by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Jesse Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2022


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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ST FRANCIS VILLA
FACILITY NUMBER: 331880693
VISIT DATE: 07/21/2022
NARRATIVE
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During the visit, LPA noted that the temperature inside the facility was approximately 88 degrees according to the thermostat inside. LPA issued a Type B citation in accordance with Title 22 Division 6 Chapter 8.

An exit interview was conducted, and a copy of this report was discussed with and provided to Mr. Dang along with copies of the LIC809-D and Appeal Rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022
LIC809 (FAS) - (06/04)
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