Green Villa

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Iby Strong, conducted an unannounced Required 1 - Year Visit. The facility file was reviewed prior to the visit. LPA met with Caregiver Ester Villar and discussed the purpose of the visit. All staff present have a current criminal record clearance. LPA conducted a tour of the facility, both inside and outside and observed the residents in care. In accordance with the Department’s Infection Control, LPA evaluated, and observed the facility's implementation of their mitigation plan to include disinfection, testing surveillance, and screening protocols as well as the use of personal protective equipment. LPA also provided consultation on todays date. No deficiencies were cited or observed on this date. The Licensee was provided a copy of their appeal rights (LIC9058 01/16). An exit interview was conducted and a copy of this report was handed to Caregiver Ester Villar.the state’s words, verbatim · CDSS document, Aug 10, 2022

Type of visit: Prelicensing

Licensing Program Analyst (LPA), Debbie Correia, conducted an announced Pre-licensing and Component IIl visit at a Residential Care Facility for the Elderly (RCFE) to ensure compliance with California Code of Regulations, Title 22, Division 6 and the Health and Safety Code. LPA Correia identified herself to Applicant Tatiana Brodsky and explained the purpose of the visit. The fire inspection was completed on July 8, 2021 by the San Diego Fire Department. Facility was cleared for six residents ages 60 and above, five (5) that may be non-ambulatory, and one (1) of which may be bedridden in a dedicated bedroom. During today's visit LPA Correia, accompanied by Applicant Brodsky, conducted a tour of the facility. According to Applicant Brodsky there will be no firearms or ammunition stored on site. LPA observed a pool on the premises that is fully fenced and locked. Indoor and outdoor passageways are free from obstructions. All window screens are clean and in good repair. Hallways are well-lit and night lights are available in the hallways. Fire, smoke alarms, and carbon monoxide detectors were all observed and operational. There is a bed for each resident's bedroom, equipped with padded covered mattresses, and pillows, observed clean and in good repair. There is sufficient closet and drawer space for resident belongings. Each resident bedroom is furnished with a chair, lamp, and a night stand. Resident bathrooms are also in good repair, equipped with handrails, Showers were equipped with non-skid shower mats. The facility maintains a sufficient supply of clean linens, sheets, bedspreads, blankets, pillowcases, mattress covers, hand towels, and washcloths. LPA observed a seven-day supply of non-perishable foods and a sample of the facility meal menu. The facility kitchen also maintains sufficient amounts of clean utensils, and equipment for proper storage of food items, and locked storage for sharp items (i.e. knives). LPA observed a confidential area for personnel and resident records, as well as a locked storage cabinet for residents' medications. Emergency exit plans, facility policy, and residents' personal rights, and infection control postings are posted in prominent areas. There is a shaded outdoor activity space, a common room available for visitors, and appropriate activity supplies. LPA observed two first aid kits maintained at the facility and a first aid manual. The facility garage remains locked when not in use, and also has a locked area to store cleaning/laundry supplies and other toxic chemicals. There is emergency lighting and generator on the premises available for safety measures. The hot water temperature measured with in compliance (111.8, 116.3, and 114.3 (x2) degrees F) in each of the 4 facility bathrooms used by residents, and the central air unit was at 76 degrees. Applicant Brodsky Administrative Certification expires on October 10, 2021. Component III was conducted at the facility with Applicant Brodsky. LPA reviewed continuing operational requirements, as well as record keeping and physical plant compliance. The applicant shall contact the Centralized Application Bureau (CAB) for completion of this pending facility application. Based on today's evaluation, the facility is in compliance with CCR, T22 and the Health and Safety Code. Final approval is forwarded to management pending review. Pre-licensing inspection is complete and the facility has no deficiencies. An exit interview was conducted, and a copy of this report, and Licensee's Rights (9058 01/16) will be sent to the Applicant's e-mail address. An electronic mail read receipt confirms delivery and receipt of these documents.the state’s words, verbatim · CDSS document, Aug 5, 2021

Type of visit: Case Management - Other

COMP II by CAB successfully completed. Facility Type: RCFE Application Type: CHOW Capacity: 6 (5 non-ab/1 bedridden) Census (if any clients in care): 4 (3 non-ambulatory and 1 bedridden Room #1) COMP II Participants: Tatiana Brodsky, Licensee Interview Method: Telephone interview On July 12, 2021 at 10:00 AM, Administrator participated in COMP II via telephone with Analyst, Celia Phomphachanh from CAB. Identification of the Administrator was verified by providing California Driver License number verbally. During COMP II, Administrator confirmed the understanding of Title 22 and Health and Safety Codes. Component II was successfully completed. Administrator were advised to email/fax signed LIC 809 with copy of photo ID to CAB. During COMP II, CAB Analyst confirmed Licensee's understanding of following areas: 1. Facility Operation: License type, client/resident populations, and program 2. Staff Qualifications and responsibilities 3. Applicant and Administrator Qualifications 4. Program Policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical Plant and Food Service 7. Application Document Review and Technical Assistance: Criminal Record Clearance, Health Screening, Fire Clearance, First Aid/CPR Certificate, Administrator Certificate, Financial Verification, Pre-licensing Inspection, Compliance History and Control of property. Interviewed concluded with Administrator. LIC 809 will be sent via email PDF to Administrator.the state’s words, verbatim · CDSS document, Jul 12, 2021