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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881546
Report Date: 11/26/2024
Date Signed: 11/26/2024 03:19:11 PM

Document Has Been Signed on 11/26/2024 03:19 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VILLA SAN JUAN ASSISTED LIVING, LLCFACILITY NUMBER:
331881546
ADMINISTRATOR/
DIRECTOR:		SAN JUAN, TEODORA L.FACILITY TYPE:
740
ADDRESS:786 DE PASSE WAYTELEPHONE:
(951) 765-9202
CITY:HEMETSTATE: CAZIP CODE:
92544
CAPACITY: 6CENSUS: 0DATE:
11/26/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:38 PM
MET WITH:Theodora San Juan AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:34 PM
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On 11/26/24 at 1:38 PM Licensing Program Analyst (LPA) Ferrer Sabarias and Licensing Program Manager (LPM) Tricia Danielson made an announced visit to the facility to conduct a pre-licensing inspection. LPA and LPM met with Applicant Teodora San Juan who accompanied LPA and LPM throughout today's inspection. The applicant has applied for a Change of Ownership (CHOW), Residential Care for the Elderly (RCFE), aged 60 and above. The facility has an approved hospice waiver for (3) of which (2) are currently receiving services. On 07/11/24 The Hemet Fire Department approved the facility for (5) non ambulatory residents and (1) bedridden resident.

The facility is a one story structure. There are three bedrooms for residents and one bedroom for staff, there are three bathrooms, dining room, living room and the kitchen. There is an attached garage, backyard with a covered patio, and plenty of space to walk and participate in outdoor activities. The facility was observed to have the required postings, and operable smoke and carbon monoxide detectors, and (1) fully charged fire extinguishers last serviced date 7/11/24. The facility was observed to have a sufficient food supply of 2 day of perishable and a 7-day supply of nonperishable food items.

Continue to LIC809-C

SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Ferrer Sabarias
LICENSING EVALUATOR SIGNATURE: DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/26/2024
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLA SAN JUAN ASSISTED LIVING, LLC
FACILITY NUMBER: 331881546
VISIT DATE: 11/26/2024
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Continue from LIC809

The facility is equipped with nonskid mats, grab bars and shower chairs. The resident bedrooms were observed to have adequate lighting, clean linen, chest of drawers, and chairs. The hot water temperature was checked and measured at 115.8 degrees Fahrenheit which is within regulatory limits. The medications are being stored inside a locked cabinet inside the hallway inside the kitchen, as well as the staff and resident files. There are no pools or bodies of water or known guns or ammunition on the premises. Completion of COMP III orientation is still pending, and facility was observed to possess valid liability insurance.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22 Chapter 6, Division 8. Based on the observations and evaluation of the facility on this date, Pre-Licensing is complete, and this facility has no deficiencies. An exit interview was conducted, and a copy of this report was provided to Teodora San Juan, Applicant.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Ferrer Sabarias
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC809 (FAS) - (06/04)
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