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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920168
Report Date: 09/26/2024
Date Signed: 09/26/2024 12:24:28 PM

Document Has Been Signed on 09/26/2024 12:24 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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:VILLA WESTLAKEFACILITY NUMBER:
345920168
ADMINISTRATOR/
DIRECTOR:		PORTELA, ALICIAFACILITY TYPE:
740
ADDRESS:490 HAWKCREST CIRCLETELEPHONE:
(916) 345-9495
CITY:SACRAMENTOSTATE: CAZIP CODE:
95835
CAPACITY: 6CENSUS: 4DATE:
09/26/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:54 AM
MET WITH:Jiani Wu, CaregiverTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
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On September 25, 2024, Licensing Program Analyst (LPA) DeAnna Williams-Lyons arrived announced to conduct a Pre-Licensing Inspection. LPA met with Alicia Portela, Administrator, who help with today's visit. This Pre-Licensing Inspection is a result of a Change of Ownership. The Administrator certificate expires 6/20/2026 and the current census is 4. The facilities Administrator’s Certificate, Emergency Disaster Plan, Resident’s Rights and Facility Sketch was available for viewing. The room temperature was 72 degrees F which is within range.

LPA inspected the interior and the exterior of the facility including the common living spaces, the kitchen, resident bedrooms and bathrooms. In the kitchen area, cabinets and drawers were reviewed. Knives and sharp objects were reviewed to make sure that they were locked and made inaccessible to the residents at all times. LPA observed there to be a sufficient amount of 2-day perishable and 7-day non-perishable food. Hot water temperatures were taken and measured at 110 degrees F, which is within the allowed range of 105-120 degrees. There’s appropriate lighting throughout the facility.

The facility is a one-story home with 5 bedrooms and 3 bathrooms. Living rooms, dining room, and areas designated for resident use were toured. Furniture and furnishings were observed to be sufficient and in good repair. Resident bedrooms and bathrooms were toured. There are 5 Bedrooms. All rooms had the required items of furniture. Window screens were on and in good repair. Bathrooms were clean, sanitary and odorless and consisted of grab bars and non-skid mats. The sink, toilet, bathtub and shower operate properly. The facility has a sufficient supply of linens, towels, bedding, etc. for residents in care. Washer and dryer was present and operating properly. Toxic substances, laundry and cleaning supplies were inaccessible.

To continue see 809-C...

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VILLA WESTLAKE
FACILITY NUMBER: 345920168
VISIT DATE: 09/26/2024
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First aid kit was present and included the required scissors, tweezers, thermometer and guide. Fire alarms, smoke alarms, and carbon monoxide detectors operate properly. Fire extinguisher is maintained and ready for emergency use. LPA inspected the exterior grounds of this facility. There are no bodies of water on the premises. The perimeter fence, side gates, and latches were in good repair. Passageways are free of obstruction and potential hazards.

There’s a centralized storage area for resident’s medication. Medication cabinet is located in cabinet in the laundry room and is locked at all times.

Resident files and 2 staff file are also located in cabinets in the laundry room which was locked . Facility has a current Infectious Control Plan. The administrator has an updated CPR and First Aid Certificates. The Disaster Plan is posted along with emergency numbers, complaint filing procedures facility theft and loss policy, and resident’s personal rights.

Component III was not completed due to the administrator being in the business and an administrator of a Skilled Nursing Facility for 5 years.

Licensure pending approval from Central Application Unit.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, no deficiencies were observed today.

An exit interview was conducted and a copy of this report was given to Jiani.

SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: DeAnna Williams-Lyons
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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