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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881248
Report Date: 03/22/2022
Date Signed: 03/22/2022 12:03:44 PM

Document Has Been Signed on 03/22/2022 12:03 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
, CA 92507
FACILITY NAME:WESTFIELD VILLA GARDENSFACILITY NUMBER:
331881248
ADMINISTRATOR:VELOSO, JUANITAFACILITY TYPE:
740
ADDRESS:3863 WEST RAMSEY STTELEPHONE:
(951) 849-7521
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY: 50CENSUS: 23DATE:
03/22/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator Alma Espinal/Applicant Kristine JuarezTIME COMPLETED:
12:15 PM
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Licensing Program Analysts (LPAs) Melody Brown and Ryan Gardner conducted an announced visit to the facility 03/22/2022 for the purpose of a Change of Ownership evaluation. At 9:30 AM, LPAs met with Administrator Alma Espinal and Applicant Kristine Juarez . An initial application for change of ownership to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 09/01/2021 for a total capacity of fifty. Fire clearance was granted on 02/01/2022 for twenty-five non-ambulatory and twenty-five bedridden residents. LPAs Brown and Gardner observed the following:

Structure:
Facility was a three level house with twenty-five resident bedrooms, thirteen resident/staff bathrooms, living room, dining area and kitchen. There was no attached car garage but have a parking lot in front of the facility.
Heating/Cooling System:
Central heating and air conditioning system installed with a central panel located in the hallway to control the entire house.
Bedrooms:
Each resident bedrooms accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, and an operable smoke alarm.
Bathrooms:
The thirteen resident/staff bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap. At 10:50 AM, LPAs tested the water temperatures in the resident bathrooms. LPAs verified water temperature was measured at 105.2 degrees Fahrenheit.

***CONTINUED ON LIC 809C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2022
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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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
, CA 92507
FACILITY NAME: WESTFIELD VILLA GARDENS
FACILITY NUMBER: 331881248
VISIT DATE: 03/22/2022
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 ***CONTINUED FROM LIC 809***
Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked drawer located in the kitchen. There was adequate room for food storage. LPAs observed the stove to be operational. Refrigerator/freezer were in working condition. There is more than seven (7) days supply of perishable foods and more than three (3) days supply of non-perishable foods. There was adequate seating for meals for all residents. Laundry room with washer and dryer was in second level of the facility. Laundry detergents and cleaning supplies are stored in the chemical storage room.
Living/Family room:
There was a living/family room with adequate seating for all residents and a working TV.
Linens and Hygiene Supplies:
An adequate supply of linens was stored in a cabinet in the main hallway of the residence.
Yards/Outside:
Patio furniture for outdoor seating observed. Gates on both side of the facility. All outdoor pathways were free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Facility sketch were observed posted in the dining room and hallway. There was Ombudsman poster and Let-Us-No poster observed.
General items:
Eleven (11) fire extinguishers were charged and located throughout the facility. Smoke alarms and carbon monoxide detectors were tested and were observed to be in working order. Resident records were stored in a locked cabinet in the office room. First Aid kit with required components, and locked area for medication storage was observed. LPAs observed a facility phone and was operational as evidenced by LPAs dialing the number. The phone number designated for the facility is 951-849-7521. There is enough Emergency water supply observed and the required 72-hour emergency food supply was observed from the regular food supply. Component III was completed on this day as well.

***CONTINUED ON LIC 809C***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
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
, CA 92507
FACILITY NAME: WESTFIELD VILLA GARDENS
FACILITY NUMBER: 331881248
VISIT DATE: 03/22/2022
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 ***CONTINUED FROM LIC 809C**
Additionally, LPAs observed facility to have required single entry point for COVID screening, upon entering the facility. LPAs observed required COVID signages throughout the facility, Visitation Vaccination Requirement Log and soap and disposable towels in bathrooms for washing hands. LPAs observed activities for the residents such as books and games.

The facility was evaluated in accordance with the CCR, Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of clients in care. Facility appears to be ready for licensure.

An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Alma Espinal and Applicant Kritine Juarez.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC809 (FAS) - (06/04)
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