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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881251
Report Date: 11/04/2022
Date Signed: 11/04/2022 09:39:56 AM

Document Has Been Signed on 11/04/2022 09:39 AM - 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:WESTHILLS VILLA GARDENSFACILITY NUMBER:
331881251
ADMINISTRATOR:MARIA JASMIN DOLORESFACILITY TYPE:
740
ADDRESS:5466 WEST WILSON ST.TELEPHONE:
9518497521
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY: 30CENSUS: 21DATE:
11/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Maria Jasmin Dolores- AdministratorTIME COMPLETED:
09:49 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced case management visit to amend and reissue forms for complaint 56-AS-20220628120253. LPA met with Administrator Maria Jasmin Dolores and explained the reason for the visit.

LPA removed a deficiency from complaint number 56-AS-20220628120253 dated 7/5/2022 and is reissuing the same deficiency during this visit. LPA found that a incident occurred on 6/20/2022 with a resident leaving the facility without staffs knowledge. The staff was informed the resident was found at a nearby location when the residents responsible party received a phone call from the police department. This incident was not reported to state licensing within the required seven (7) day time frame which poses a potential health, safety, or personal rights risk to persons in care.

During today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.


An exit interview was conducted, and this report was discussed and provided to Administrator Maria Jasmin Dolores.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2022
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 11/04/2022 09:39 AM - It Cannot Be Edited


Created By: Ryan Gardner On 11/04/2022 at 09:11 AM
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
, CA 92507

FACILITY NAME: WESTHILLS VILLA GARDENS
FACILITY NUMBER: 331881251

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/06/2022
Section Cited
CCR
87211(a)(1)(D)

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87211. Reporting Requirements.(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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The licensee has agreed to read regulation 87211 entirely and send LPA self-certify letter that the regulation was read and understood. The licensee has agreed send licensing a special incident report for this incident. The licensee has agreed that moving forward all special incidents will be reported to licensing within the required time frame.
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This requirement was not met based on evidence by interview and document review. The licensee did not comply with the section cited above by not reporting an incident with a resident to state licensing within the required seven (7) day timeframe which poses a potential health, safety, or personal rights risk to persons in care.
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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:Karen Clemons
LICENSING EVALUATOR NAME:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2022


LIC809 (FAS) - (06/04)
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