405850354-7-27-2023-29-AS-DCHZ-CU5RX9-20230727132421

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850354
Report Date: 07/27/2023
Date Signed: 07/27/2023 01:25:15 PM

Document Has Been Signed on 07/27/2023 01:25 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VILLA GARDENS		FACILITY NUMBER:	405850354
ADMINISTRATOR:	CASTANIAGA, JANELYN		FACILITY TYPE:	740
ADDRESS:	9385 SANTA CLARA RD.		TELEPHONE:	(805) 464-2098
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY: 6		CENSUS: 0	DATE:	07/27/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Janelyn Castaniaga, Applicant		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/27/23 at 9:58 am, Licensing Program Analyst (LPA) Chavez conducted a pre-licensing visit to the facility noted above. LPA met with Janelyn Castaniaga, Applicant. This is a change of location application. A dementia program was included in the plan of operation. A Hospice Waiver has been approved for four (4) residents. At 10:01 am, LPA conducted a physical plant tour with the applicant of the inside and outside of the facility. There are zero (0) residents occupying the facility. The facility is a one-story building. An approved fire clearance was received, clearing the facility for six (6) non-ambulatory residents; zero (0) ambulatory residents; and, zero (0) bedridden residents. The facility has three (3) private resident bedrooms with a capacity of two residents per room. All resident rooms have direct exits to the outside. Resident rooms have beds, nightstands, lamps, and closet space. Each room has only one chair. Applicant will place an additional chair in resident rooms (3). Resident room #1 is missing two (2) chests of drawers, room #2 is missing one chest of drawers, and room #3 is missing two dressers. Applicant will add furniture to rooms and send photos to LPA. Room #2 has a closet with two doors. One door opens fully, the other does not due to the bed abutting it. Applicant will make an adjustment so that residents have full access to the closet. Applicant will correct the door so it moves freely and send video to LPA. The beds are furnished with box springs, comfortable mattress and clean linen which includes top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Beds are missing mattress pads. Applicant will add mattress pads and send photos to LPA. Lighting in the rooms appeared adequate. The rooms are equipped with overhead fans and lighting. There is a switch by the door to turn lights/fan on/off and chains on the fans to turn each on/off. LPA advised applicant to leave the light chain on so that when residents enter the room and click the light switch on the wall, the overhead light comes on. Continued on 809-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA GARDENS	FACILITY NUMBER: 405850354
	VISIT DATE: 07/27/2023

NARRATIVE

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The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. Two (2) staff rooms and bathrooms are located to the left of the front entrance. Staff rooms are secure to ensure residents do not have access. All rooms were free of odors. All window screens were clean and maintained in good repair. The screen on the sliding glass door at the back of the house by the dining room is difficult to open/close, the handle is broken, and the screen has a tear of approximately 6 inches. Applicant will repair/replace screen and send video to LPA.

The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioning properly during the time of the visit. There is a fire extinguisher in the hall across from the kitchen toward the garage. The extinguisher is fully charged and was last tested on 6/14/23.

There is one (1) bathroom in the hallway on the west side of the facility which is designated as a staff bathroom. Resident bedrooms #1 and #2 share a bathroom, accessible from each room. Room #3 has a bathroom attached. The resident bathrooms have showers with non-skid materials. The toilets have grab bars or sink counters and showers have grab bars. The hot water temperature was tested in the bathrooms and the kitchen. Bath #1 registered at 127.9 F and bath #2 at 122.2 F. Temperatures exceeded the required range of 105 F to 120 F. Applicant will correct water temperatures and send videos (2) to LPA.

The facility does not have a locked cabinet or room for resident and staff records and resident medications. Applicant will secure items and send photo or video to LPA. The first aid supplies were complete, including a thermometer, scissors, tweezers, and a current version of a first aid manual. They were stored on a table in the hallway across from the kitchen. Applicant will secure first aid kit and send photo to LPA.

Continued on 809-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA GARDENS	FACILITY NUMBER: 405850354
	VISIT DATE: 07/27/2023

NARRATIVE

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Kitchen knives are stored in a locked cabinet in the kitchen. The stove has on/off knobs, and the kitchen is accessible to residents in care. Applicant will remove the knobs or ensure residents do not have access to the kitchen and send photos to LPA. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F), however, the refrigerator was recorded at 46 F. Regulation is 40 F or below. Applicant will adjust refrigerator temperature and send a photo to LPA. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. The one (1) trash can has a lid, however, it did not fully close. Applicant will repair/replace and send video to LPA. Kitchen, laundry and house cleaning supplies are stored in the locked laundry room. No vermin were observed in the facility.

The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and/or activity supplies in the living room. There was sufficient space to accommodate both indoor and outdoor activities. There are night lights in hallways and passageways. The physical plant was checked for cleanliness and condition. Living room and dining room furniture were checked and in good condition. The facility has crews working on the property and common areas indoors have dirty floors. Applicant will ensure proper cleaning so that the floors are safe and sanitary and send photos to LPA.

There is a screened fireplace in the dining room near the kitchen. There are no alarms on exterior doors. Applicant will add alarms and send videos to LPA. The physical plant is consistent with the submitted facility sketch/floor plan. The facility has a furnace which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. LPA observed the thermostat at 77 F during the visit.

The laundry room is located in the hall leading from the kitchen to the garage. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in the laundry room. There is a functioning telephone on the premises in the living room, phone number 805-464-2098. The emergency exiting plans/sketch are not posted in hallways and at the entrance. Applicant will post these and send videos to LPA.
Continued on 809-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA GARDENS	FACILITY NUMBER: 405850354
	VISIT DATE: 07/27/2023

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LPA observed the Bill of Rights and Right to Residential Council and Complaint Poster posted in the hall across from the kitchen. Applicant needs to post emergency telephone numbers and non-discrimination statement in a common area. Applicant will post and send photos to LPA.

All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. However, the ramps leading from resident bedrooms (3) have approximately a 3-inch space on each side where residents could fall/trip. Additionally, there is a ramp leading from the deck outside the resident rooms to the backyard which has the same 3-inch gap. Applicant will correct and send photos to LPA. The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the facility with tables and chairs where residents can sit. A gazebo is being built in the backyard. The back yard and side yards are fenced. There are two pedestrian gates on the east and west side of the property which do not have self-locking latches and automatic closing mechanisms. The gate on the east side has a chain and lock on it. Applicant will add self-locking latches and auto-closing mechanisms to gates and remove chain/lock and send videos to LPA. The facility has a 3-foot tall fence around the eastside deck with an open space of approximately 15 feet between the end of the fence and the garage. There is a step down from the deck onto an uneven surface which could be a hazard to residents. Applicant will correct and send video to LPA. There are two (2) sheds on the southeast side of the deck. LPA observed stored items. Applicant says these sheds will be used for storage only. There is a 3-car garage with two vehicle entrance doors. The 1-car garage does not have a door opener and can be opened from the outside. Applicant will secure door from the inside and send photo to LPA. There are no bodies of water on the premises at this time.

The items in bold font must be corrected prior to licensure. Submit proof of corrections, along with a copy of this report, to LPA so that your application may be completed.

Exit interview conducted and a copy of report given to applicant.

This report will be sent to the Centralized Application Bureau (CAB) once all corrections are received. You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023

LIC809 (FAS) - (06/04)

Page: 4 of 4