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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850218
Report Date: 03/11/2025
Date Signed: 03/11/2025 04:51:52 PM

Document Has Been Signed on 03/11/2025 04:51 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 IIFACILITY NUMBER:
425850218
ADMINISTRATOR/
DIRECTOR:		VILLAROS, JENNIFERFACILITY TYPE:
740
ADDRESS:946 WEST BUNNYTELEPHONE:
(805) 614-4442
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 6CENSUS: 5DATE:
03/11/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:53 PM
MET WITH:Jennifer Villaros TIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Rankin conducted a 1-year annual visit to the facility above. LPA met with Licensee/Administrators Jennifer Villaros and Jessica Rust and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with the Administrator. The following was inspected and noted during the annual visit:

PHYSICAL PLANT & ENVIRONMENTAL SAFETY: The facility has five (5) resident bedrooms and two (2) resident bathrooms. There is an approved fire clearance capacity of six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility has an approved Hospice Waiver for six (6) residents. The showers have non-skid floors. 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 in care and locked in cupboards. The facility has sufficient space inside and outside for activities and visiting. This is a two (2) story facility in which the first floor is for residents in care at the facility and the second floor is specifically for Staff members. The second story is inaccessible and off limits to residents of the facility. The first-floor indoor areas of the facility consist of resident bedrooms, restrooms, shower areas, a Centrally Stored Medication area, kitchen, dining room, storage area closets/rooms, living room, family room, staff office area and an entrance area upon entry into the facility. All resident bedrooms were furnished and contained beds, chairs, bedside tables, and lamps. There is also an ample supply of linens and towels. LPA observed night-lights present in the main bathroom, kitchen, and family room. The facility contains an outside area for residents to utilize for outdoor activities/outdoor visitations and an outdoor patio area with furniture and shade. There is a locked tool shed in the backyard of the facility. The shed contained outdoor maintenance materials for the facility. The facility has carbon monoxide detectors which were tested and were working at time of visit. Fire extinguishers were observed charged and inspected last on 12/11/24. The facility is clean, safe, and sanitary.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA-CARE HOME II
FACILITY NUMBER: 425850218
VISIT DATE: 03/11/2025
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FOOD SERVICE: The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. All food is covered and stored. Emergency supply of food and water is available. Kitchen areas are kept clean and free of insects and rodents. LPA inspected the kitchen/food service area and observed that knives/sharp instruments are stored in a locked drawer inaccessible to residents of the facility. There was emergency food and water in the garage of the facility.

PERSONNEL RECORDS & TRAINING: The facility employes seven (7) staff and three (3) Administrators. Staff records are kept confidential. LPA reviewed five (5) staff files for 1st AID/CPR, Fingerprint clearances, Applications, Health exam with TB results, and Criminal Record statement. Administrator certificate expires 08/14/25. Annual training was complete.



RESIDENT RECORDS & INCIDENT REPORTS: The facility keeps confidential files on each resident. Five (5) 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, and Personal Rights. All records were complete. Facility does submit incident reports to the department when required.

MEDICATIONS: The facility maintains a locked centralized storage area for resident medications. Centrally Stored Medications are in a locked storage containment area within an indoor closet area of the facility. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. The medications in the facility were labeled appropriately with no additional or prohibited marking's by the facility.

FACILITY DOCUMENTATION: There are required postings throughout the facility, including emergency exit plans with necessary telephone numbers. The facility keeps posted copies of facility documentation such as the RCFE License Certificate, LIC 500 Personnel Report, Documentation of Facility Waivers, Emergency Disaster Plan for Residential Care Facilities for the Elderly (RCFE), Certificate of Liability Insurance, Valid Administrator Certificate, and a Facility Sketch.

No deficiencies cited. Exit interview conducted. A copy of the report was issued to the facility.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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