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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850219
Report Date: 12/19/2024
Date Signed: 12/19/2024 03:55:17 PM

Document Has Been Signed on 12/19/2024 03:55 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 IVFACILITY NUMBER:
425850219
ADMINISTRATOR/
DIRECTOR:		VILLAROS, JENNIFERFACILITY TYPE:
740
ADDRESS:1422 SONYA LANETELEPHONE:
(805) 623-2939
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 6CENSUS: DATE:
12/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:35 AM
MET WITH:Jeniifer Villaros, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Erika Miller arrived at 10:35 a.m. to conduct a 1-year required annual visit. LPA met with Jennifer Villaros, Administrator.

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

Infection Control: The facility has a current Infection Control Plan. The facility has a supply of PPE and have additional PPE stored at their other facilities, which are readily available.Quarantined or isolated individuals will have meals and medication delivered to rooms. Staff are trained on infection control and the use of Personal Protective Equipment (PPE).

Physical Plant & Environment Safety: LPA was authorized to enter and inspect facility. LPA toured resident rooms and observed that rooms were tidy and free of odor. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have slip resistant mats. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant and cleaning solutions are inaccessible to residents in care and locked in closet. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard for client use with plenty of shade. The facility has telephone and internet service for resident use. The fire extinguisher was last charged and inspected on 12/11/24. The facility has smoke and carbon monoxide detectors that were tested and working properly.
Continued 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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 IV
FACILITY NUMBER: 425850219
VISIT DATE: 12/19/2024
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Disaster Preparedness: The current emergency disaster forms were posted. The facility last conducted a quarterly disaster drill/training on 10/1/24. 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.

Residents with Special Health Needs: The facility does accept dementia residents in care. The facility has 1 self-latching gate on side of the home. The facility does not have delayed egress, locked doors or gates. Exit door alarms are working.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
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Document Has Been Signed on 12/19/2024 03:55 PM - It Cannot Be Edited


Created By: Erika Miller On 12/19/2024 at 03:44 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA-CARE HOME IV
FACILITY NUMBER: 425850219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when Licensee did not esure that expired medicaitons were destroyed and when the start date was notated on the presicption label, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/27/2024
Plan of Correction
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Submit statement or understaniding signed by all staff that they must not alter or make notations on presciption label. In addtion, Licensee will ensure that audit of medications will be conducted periodically to purge expired medicaitons.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Erika Miller
LICENSING EVALUATOR SIGNATURE:
DATE: 12/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/19/2024


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