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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802416
Report Date: 12/18/2024
Date Signed: 12/19/2024 10:35:40 AM

Document Has Been Signed on 12/19/2024 10:35 AM - 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 TERESA RESIDENTIAL CAREFACILITY NUMBER:
565802416
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, TINA MARIEFACILITY TYPE:
740
ADDRESS:821 TERESA STREETTELEPHONE:
(805) 604-7772
CITY:OXNARDSTATE: CAZIP CODE:
93030
CAPACITY: 6CENSUS: 5DATE:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:50 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Kristin Kontilis conducted an unannounced required Annual Inspection at the above-named facility. Upon arrival, LPA met with two staff members and explained the purpose of the visit. At the time of arrival, there were two (2) staff on duty and five (5) residents in care. Licensee George Yazbek arrived at approximately 12:33 pm. Administrator Tina Marie Martinez arrived at approximately 12:35 pm.
Entrance interview conducted.
The facility is a one-story Residential Care Facility for the Elderly (RCFE). Currently, there are no residents on hospice and no residents are bedridden.
A tour of the physical environment and accommodations were assessed, and the following was noted: LPA observed the required posting of the complaint poster and Resident’s Rights. LPA inspected the one-story facility for fire safety, personal accommodations, and food service.
The physical environment was checked for cleanliness and condition. Walls, windows, ceilings, doors, floors and floor coverings were checked. The facility was seen to be in good repair inside and outside. There is one fire extinguisher located in the kitchen and dining area and last serviced on 6/12/2024. There is one carbon monoxide detector and six (6) smoke alarms throughout the facility. At approximately 12:41 pm, Licensee tested the detector and alarms. All are in good working order.
The kitchen area was sufficiently stocked with seven days of non-perishables and two days of perishables. Snacks and beverages are readily available for Residents. Frozen foods are properly wrapped and stored appropriately. LPA observed the kitchen cabinets, refrigerator, stove, and counters are clean.

Please continue to 809-C, Pg 2.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA TERESA RESIDENTIAL CARE
FACILITY NUMBER: 565802416
VISIT DATE: 12/18/2024
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 Medications, First Aid kit, and additional first aid supplies are kept in a locked centrally stored cabinet. First aid kit was observed to be complete.
Residents participate independently in activities such as arts and crafts, watch game shows, conduct conversations, listen to music, go out on outings with friends and family and medical appointments, and outdoor visitations.
The front yard consists of walkway and landscaping. The backyard has walkways and an outdoor visiting area. There are no bodies of water. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. A locked garage is located at the front of the home used for storing supplies.
The kitchen, living room, and dining area are neat and clean. The facility maintains a comfortable temperature.
Bedrooms 1 and 2 are private bedrooms and Bedroom 3-4 is a shared bedroom. Bedrooms 1, 2, and 3-4 share a bathroom off the hallway located near the bedrooms. Bedroom 5-6 is a shared bedroom with a private bath. The bathrooms have secure grab bars and no skid flooring.
Medication inventory revealed an unexplainable under count of one (1) medication for Resident 1 (R1) and an over count of one medication for R1. Medication inventory revealed Resident 2 (R2) had an over count of one medication.
Residents’ files were reviewed. LPA noted that on file for each resident was the following: Physician’s Reports, Admission Agreements, Health Screenings, Medical Assessments, Identification and Emergency information, Appraisals/Needs Service Plan, and Centrally Stored Medication Administration Records.
Staff files were reviewed. LPA noted that staff files are current with health screenings, First Aid & CPR certifications, trainings, and background clearances. All persons associated with the facility have criminal record clearance. Administrator certificate is valid.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. Copy of report and Appeal Rights issued at the time of the visit.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2024 10:35 AM - It Cannot Be Edited


Created By: Kristin Kontilis On 12/18/2024 at 03:20 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 TERESA RESIDENTIAL CARE
FACILITY NUMBER: 565802416

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465((c)(2)
87465(c)(2) Incidental and Medical Care: ....Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above when there was an unexplainable under count for one medication for R1 and one over count for one medication for R1; and one overcount for one medication for R2 which poses an immediate health and safety risk to residents in care.
POC Due Date: 12/20/2024
Plan of Correction
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Licensee and Administrator agree to conduct a complete medication inventory for all residents; create a log to track dates and times medications are administered. Licensee and Administrator agree to send copy of log via email to LPA.
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:Kristin Kontilis
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2024


LIC809 (FAS) - (06/04)
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