405850354-8-22-2024-29-AS-RDLN-D8DUDM-20240822152948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850354
Report Date: 08/22/2024
Date Signed: 08/22/2024 03:31:08 PM

Document Has Been Signed on 08/22/2024 03:31 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/ DIRECTOR:	CASTANIAGA, JANELYN		FACILITY TYPE:	740
ADDRESS:	9385 SANTA CLARA RD.		TELEPHONE:	(805) 464-2098
CITY:	ATASCADERO	STATE: CA	ZIP CODE:	93422
CAPACITY: 6		CENSUS: 2	DATE:	08/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:30 AM
MET WITH:	Janelyn Castaniaga, Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:45 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	Licensing Program Analyst (LPA) De Leon arrived at 10:30 am to conducted a 1 year annual visit to the facility above. LPA met with Licensee/Administrator Janelyn Castaniaga and explained the purpose of the visit. A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit: Infection Control: The facility has a current Infection Control Plan. The facility has a sign in and out binder for visitors at entry with hand sanitizer. The bathrooms have toilet paper, hand dryer, hand soap, and hand washing signs and paper towels. The facility has EPA approved disinfectants spray and cleaners. The facility has a 30 day supply of PPE. Quarantined or isolated individuals will have meals and medication delivered to rooms when and if needed. All trash cans and waste baskets have tight fitting covers. Operational Requirements: The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance effective 05/01/2024. The facility is approved for a capacity of 6 Non-Ambulatory and a Hospice waiver approved for 4. Physical Plant & Environmental Safety: The facility is a 5 bedroom home with 3 double rooms dedicated for residents. The facility has 3 bathrooms to be used by residents and 1 staff bathroom currently occupying 2 residents and employs 2 staff and 2 administrators. The facility has 2 bedrooms for live-in staff. The facility is clean, safe and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors. The lighting and lamps are sufficient for the use of the facility and for resident comfort. The facility kitchen is clean, safe and sanitary. The kitchen has a gate to make the range inaccessible to dementia residents, and it does not lock. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents are locked in the laundry room and locked garage. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for resident use with furniture and plenty of shade. Telephone and internet service is provided for resident use. The facility has a working washer and dryer. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA GARDENS	FACILITY NUMBER: 405850354
	VISIT DATE: 08/22/2024

NARRATIVE

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Staffing: The facility employes 3 staff and 2 Administrators. Staff records are kept confidential. LPA reviewed staff folders, several staff work at the Licensee other facility and records are kept there, explained to Administrator that staff on the LIC 500 must have staff files available for review on visit. LPA verified each administrator to have current 1st Aid/CPR. Administrator Certificate expires 10/22/2025. Administrator will email LPA the remaining records.

Personnel Records & Training: The facility keeps confidential files for each staff member at the other facility. LPA explained that all staff listed on the LIC. 500 must have training conducted annually and it must be available at the facility to verify annual training records.

Resident Rights & Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license is posted. Internet is provided to residents in care, confidentiality and privacy is given.

Planned Activities: The faciity has supplies for activities. The residents currently in care watch TV, go for walks, have discussions with staff and exercise a few days a week.

Food Service: The facility handles and prepares food safely. The facility has 2 day perishables and 7 day non-perishables to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen areas are kept clean and free from litter, rodents, vermin and insects. Kitchen staff were observed for personal hygiene and food sanitation practices.

Incidental Medical and Dental: Facility provides or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications for all resident in care are centrally stored. LPA reviewed medications and records. No medications label were altered, no medications were expired, and all medication was stored in original containers. Medication are given as prescribed with physicians orders. Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 08/22/2024

NARRATIVE

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Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Two files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources for any of the residents in care. Facility does submit incident reports to the department when required.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. Facility has emergency food and water supply, flash lights with batteries, and a cooler with ice packs for medications. The facility has several evacuation sites. The facility has generator.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked or in accessible to residents in care. The facility does not have any resident on oxygen. The facility currently has 1 resident receiving hospice services. The facility currently has no residents receiving home health services. Hospice and Home Health care plans are kept on file and up to date. The facility does not have any delayed egress. The facility has alarmed exiting doors and gates. The facility has three self latching, self closing gates with alarms. There are no bodies of water on the premises.

LPA conducted interviews with 1 staff and 1 resident.

Exit interview conducted and copy of report printed and emailed to Licensee/Administrator

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024

LIC809 (FAS) - (06/04)

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