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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530072
Report Date: 10/27/2023
Date Signed: 10/27/2023 07:42:18 PM

Document Has Been Signed on 10/27/2023 07:42 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VILLA DESCANSO DE AMORFACILITY NUMBER:
365530072
ADMINISTRATOR:THOMPSON, GABRIELAFACILITY TYPE:
740
ADDRESS:15453 ELM LANETELEPHONE:
(909) 393-6201
CITY:CHINO HILLSSTATE: CAZIP CODE:
91709
CAPACITY: 6CENSUS: 6DATE:
10/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:22 PM
MET WITH:Sharee GlissonTIME COMPLETED:
08:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to the facility for complaint control number 18-AS-20220207165851. During the complaint visit, LPA Rico completed a case management visit to cite for a deficiency found during the complaint record review.

During record review, Licensee did not provide a completed Physician Report LIC 602 for R5. The LIC 602 provided to LPA was incomplete. Licensee must provide a completed Physician Report on file.

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

An exit interview was conducted, and this report was discussed through the phone to Gabriela Thompson and provided to Sharee Glisson , along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
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 10/27/2023 07:42 PM - It Cannot Be Edited


Created By: Mary Rico On 10/27/2023 at 04:40 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: VILLA DESCANSO DE AMOR
FACILITY NUMBER: 365530072

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2023
Section Cited
CCR
87458(a)

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87458(a) Medical Assessment
(a)Prior to a person's acceptance as a resident, .. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.This requirement is not met as evidenced
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Licensee has agreed to send LPA Physician's Report for R5. Completed and updated by Physician.
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Based on recrod review the licensee did not comply with the section cited above by not having R5 physician reports, which poses a potiential health and safety risk to persons in care
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POC due date 11/3/2023

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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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023


LIC809 (FAS) - (06/04)
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