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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850214
Report Date: 09/30/2024
Date Signed: 09/30/2024 01:27:19 PM

Document Has Been Signed on 09/30/2024 01:27 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:VILLA-CARE HOME IFACILITY NUMBER:
425850214
ADMINISTRATOR/
DIRECTOR:		RUST, JESSICAFACILITY TYPE:
740
ADDRESS:938 WEST BUNNY AVENUETELEPHONE:
(805) 928-5654
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 6CENSUS: 5DATE:
09/30/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Jessica RustTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) M. Rankin conducted a Case Management - Deficiencies visit to deliver findings. LPA met with Jessica Rust Administrator and explained the reason for the visit.

During the Department’s investigation of complaint #29-AS-20240405155913, the following deficiency was observed:

On 03/29/2024, at approximately 1:30am, Resident #1 (R1) had an unwitnessed fall and sustained a fractured nose. Interviews and review of the Unusual Incident/Injury Report submitted by the facility revealed R1’s resident representative was notified of the incident by the hospital.

Citation issued, exit interview, appeal rights given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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Document Has Been Signed on 09/30/2024 01:27 PM - It Cannot Be Edited


Created By: Melisa Rankin On 09/30/2024 at 11:33 AM
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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA-CARE HOME I
FACILITY NUMBER: 425850214

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2024
Section Cited
CCR
87468.1(8)

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87468.1(8) Personal Rights of Residents in All Facilities (8)To have their representatives regularly informed by the licensee of activities related to care...as appropriate to their needs. This requirement is not met as evidenced by:
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The licensee will submit a plan describing how you will ensure resident representatives are notified of resident change of condition. Submit proof to CCL by 10/14/24.
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Based on records review and interviews, the licensee did not comply with the section cited above. The facility did not notify R1’s resident representative of R1’s fall on 03/29/2024, which posed
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 a potential health and safety risk to residents in care.

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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:Kelly Burley
LICENSING EVALUATOR NAME:Melisa Rankin
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


LIC809 (FAS) - (06/04)
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