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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850301
Report Date: 12/23/2024
Date Signed: 12/23/2024 03:04:13 PM

Document Has Been Signed on 12/23/2024 03:04 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:VILLARIANA CAREFACILITY NUMBER:
565850301
ADMINISTRATOR/
DIRECTOR:		BUSCH, HELEN ROSE T.FACILITY TYPE:
740
ADDRESS:4731 READING DRIVETELEPHONE:
(319) 360-1230
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 6CENSUS: 5DATE:
12/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Johnna Udden -Co- Administrator TIME VISIT/
INSPECTION COMPLETED:
03:05 PM
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At 1:20 p.m. Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit. The LPA was greeted by staff and informed them of the visit. Staff called the Administrator who arrived shortly after. LPA met with Co-Administrator Johnna Udden and informed them of the reason for the visit.

At 1:25 p.m. the LPA conducted a tour of the physical plant with the Administrator to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted: Facility is a single-story residence that consists of four (4) resident bedrooms, one (1) staff room, and three (3) restrooms. The LPA observed one (1) fire extinguishers which was fully charged and last serviced 10/09/2024. At 2:31 p.m. all smoke alarms and carbon monoxide detectors were tested and functioned properly. The LPA observed all required postings in the hallway near the entrance area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.

Kitchen: The LPA inspected the kitchen/food service area at 1:35 p.m. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. Chemical storage is kept locked under the sink. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 115.1 degrees Fahrenheit at 1:42 p.m.

Bedrooms: The four (4) resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.
(PAGE 1) Report Continued on LIC 809C PAGE 2...
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: VILLARIANA CARE
FACILITY NUMBER: 565850301
VISIT DATE: 12/23/2024
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(PAGE 2) Report Continued from LIC 809 PAGE 1...
RESTROOMS: There are three (3) restrooms of which two (2) are designated for resident use. Resident restrooms were observed to be equipped with nonskid surfaces. Grab bars were observed in both bathrooms. The restrooms were sufficiently stocked with supplies and paper towels. The water temperature was measured in both resident restrooms between 106.9-108.1 degrees Fahrenheit all within the required range.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. The last emergency disaster drill took place on 11/15/2024. Activities were observed in the common areas. The fireplace was adequately screened at the time of the visit.

GARAGE/BACKYARD: The garage is maintained locked at all times. LPA observed an adequate amount of emergency food and water. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water noted at the time of the visit. Laundry detergent was observed in a locked cabinet in the garage. LPA observed two (2) self latching gates.
MEDICATIONS: Medications review began at approximately 2:01 p.m. The medications are in a locked cabinets adjacent to the kitchen and living room. Medications for five (5) residents were reviewed. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. No medication errors observed at this time.

Interviews: The LPA conducted two (2) staff and two (2) resident Interviews. Interviews reveled that staff are knowledgeable in resident rights, forms of abuse and reporting procedures. No immediate concerns were voiced at the time of the visit.

Documents obtained: LIC 500 Personnel Report, LIC 9020 Resident Roster, and Liability Insurance.

Due to time constraints an LPA will return to complete the annual at a later date.
No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Erica Mosley
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2024
LIC809 (FAS) - (06/04)
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