Willow Glen Residence

Type of visit: Required - 1 Year

On 8/23/2023 at 12:05PM, Licensing Program Analysts (LPAs) L. Hall and L. Alexander conducted an unannounced 1-Year Required inspection. LPAs met with Levi Villareal, Administrator, and explained the purpose of the visit. The Administrator certificate is pending and expired 3/26/2023. Facility does not have any residents at this time. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of four (4) bedrooms and two (2) bathrooms. No bodies of water was observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 109.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 08/23/2022. First aid kit was observed to be complete. Continued on LIC809. Continued from LIC809. LPA did not review any staff files. LPA requested the following documents to be submitted to CCLD by 8/30/2023. Resident Roster LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan (9 pages) Liability Insurance No deficiencies cited during this visit. Exit interview conducted and a copy of this report provided.the state’s words, verbatim · CDSS document, Aug 23, 2023

Type of visit: POC

On 11/09/2022 at 10:55AM, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Licensee, Levi Villareal and explain the purpose of the visit. LPA visited the facility on 8/3/2022 and observed that the facility did not have a qualified Administrator employed. LPA cited and assessed ongoing civil penalties under section 87405(a) Administrator – Qualifications and Duties. Licensee was given a plan of correction date. Licensee telephone LPA on 9/19/2022 to request an extension for the plan of correction which LPA granted until 10/17/2022. LPA conducted another visit on 10/19/2022 and gave a new POC date of 10/26/2022. On today’s date Licensee have not hired an Administrator or have not recertified as the Administrator. A civil penalty of $1400.00 will be assessed on today’s date from 10/27/2022 to 11/09/2022. Facility is subject to ongoing civil penalties of $100.00 per day until the deficiency is corrected. Exit interview conducted. A copy of this report, LIC421FC, and appeal rights provided.the state’s words, verbatim · CDSS document, Nov 9, 2022

Type of visit: Case Management - Other

On 10/19/2022 at 1:25PM, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Licensee, Levi Villareal and explained the purpose of the visit. LPA visited the facility on 8/3/2022 and observed that the facility did not have a qualified Administrator employed. LPA cited and assessed ongoing civil penalties under section 87405(a) Administrator – Qualifications and Duties. Licensee was given a plan of correction date that was not met. Licensee telephoned LPA on 9/19/2022 to request an extension for the plan of correction which LPA granted until 10/17/2022. On today’s date Licensee have not hired an Administrator or have not recertified as the Administrator. LPA explained to Licensee that he will be recited today and if not corrected civil penalties will be assessed. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Oct 19, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Oct 26, 2022

87405 (a) All facilities shall have a qualified and currently certified administrator...The administrator shall... be on the premises a sufficient number of hours... there shall be coverage by a designated substitute... This requirement was not met as evidence by: Based on observation and record review, the licensee did not comply with the section cited above in having a current administrator certificate which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Oct 19, 2022

Plan of correction: Licensee agreed to hire a qualified Administrator and submit all documents required to change the name of the Administrator for the facility to CCLD by POC date.

Type of visit: POC

On 8/19/2022, at 1:00PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct proof of correction (POC) visit. LPA met with Levi Villareal, Licensee, and explained the purpose of the visit. Facility has the following deficiencies that were not cleared: 87632(a), LPA have not received documents to request a hospice waiver from Licensee after annual inspection visit 8/11/2022. 87405(a), LPA have not received plan on what facility would do until they hire an Administrator or recertify as Administrator, after annual inspection visit 8/11/2022. LPA gave 30-days (9/19/2022) for Administrator new hire. 87506(a), LPA did not receive self-certification stating that R1's file was complete and on today's date R1's file is still not complete after annual inspection visit 8/11/2022. Civil Penalties for 87632(a) in the amount of $700 assessed immediately for the period of 8/13/2022 - 8/19/2022. Civil Penalties for 87405(a) in the amount of $100 assessed immediately for the period of 8/19/200 - 8/19/2022. Civil Penalties for 87506(a) in the amount of $100 assessed immediately for the period of 8/19-2022 - 8/19/2022. Continued on LIC809C. Continued from LIC809. Civil Penalties in the total amount of $900 is assessed today for failure to meet POC date for deficiencies. Facility is subject to ongoing civil penalties until deficiency is corrected. Exit interview conducted. A copy of this report, appeal rights provided and LIC421FC provided.the state’s words, verbatim · CDSS document, Aug 19, 2022

Type of visit: Case Management - Other

On 8/19/2022 at 1:00PM, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a Case Management visit. LPA met with Licensee, Levi Villareal and explain the purpose of the visit. LPA attempted to visit the facility on 8/3/2022 for an annual inspection and on 8/18/2022 for a POC visit. On both occasions LPA was not able to enter the facility. LPA was not able to open the gate to get to the front door of the facility. LPA observed a doorbell attached to the gate but it was not operable. LPA called the facility several times while standing outside of the gate as well as left a message. Licensee did not open the gate or return LPA's call. Licensee will submit an addendum to the plan of operation for dementia care. Civil penalty of $500.00 will be assessed on today's date. Deficiency is cited from Title 22 California Code of Regulations (see 809D). A $500.00 civil penalty is assessed for deficiency # 87755(a). Failure to submit proof of correction by due date may result in additional civil penalties. Exit interview conducted. A copy of this report, LIC9098, LIC421M, and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 19, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87755(a) · Plan of correction due date: Aug 20, 2022

87755 Inspection Authority of the Licensing Agency (a) Any duly authorized officer, employee... of the licensing agency may... enter and inspect the entire premise... at any time, with or without advance notice. This requirement was not as evidence by: Based on LPA's observation the Licensee did not comply with the section cited above in facility being accessible for Department, which poses a potential health and safety risk for persons in care.the state’s words, verbatim · CDSS document, Aug 19, 2022

Plan of correction: Licensee agreed to attach new doorbell, to review and abide by regulation 87755, and to submit photo of new doorbell and copy of self-certification to CCLD by POC date.

Type of visit: Required - 1 Year

On 8/3/2022 at 09:25AM, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct a 1-year annual infection control inspection. Upon arrival LPA rang doorbell that is located outside of locked entry gate. LPA called facility 3xs and the voicemail box was full. LPA was able to see a recycling bin outside of facility. No cars were present. LPA was able to peak through fence and saw the blinds were open. LPA will attempt visit at a later date. On 8/11/2022 at 11:25AM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Levi Villareal, Administrator and explained the purpose of the visit. Upon entry, LPA's temperature was not checked. LPA observed screening station and COVID-19 signs posted near screening station. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and back yard. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. Hot water temperature in the shared clients’ bathroom was measured at 116.2 degrees Fahrenheit. Fire extinguisher last serviced on 7/19/2019. There is a minimum of 7-day non-perishables and 2-day perishables foods. Continued on LIC809C. Continued from LIC809. During record review, LPA observed facility has a copy of the mitigation plan on file. LPA observed food and paper supplies are sufficient. The following deficiencies were observed: -At 10:42AM, LPA observed Ajax, windex, and raid in unlocked cabinet under kitchen sink. -At 11:55AM, LPA observed R1 on hospice care. Facility does not have hospice waiver. -At 12:05PM, LPA observed while reviewing R1's file that the file is missing the following documents: personal rights, personal safeguard, Identification and emergency information, and a care plan for hospice services. The following documents are outdated appraisal needs and services plan, and physician's report. -At 12:15PM, LPA observed that Administrator certificate expired on 2/19/2022. -At 12:20PM, LPA observed that Administrator was not following requirement duties for Administrator. LPA request the following documents to be submitted to CCLD by 8/18/2022. LIC 500 Personnel Report LIC 610E Emergency Disaster Plan The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties. Exit interview conducted. A copy of this report provided and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 3, 2022

The state marks this report as 9 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 08/17/2021 at 02:45PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Levi Villareal, Administrator and explained the purpose of the visit. Upon entry, LPA's temperature was not checked. LPA observed screening station at entrance with hand sanitizer, thermometer, face mask. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, and kitchen. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters were posted. During record review, LPA observed visitors log. LPA observed PPE, food, and paper supplies are sufficient. -At 2:50PM, LPA observed facility did not have a mitigation plan on file. The following deficiency was observed (see LIC809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency may result in Civil Penalties. Exit interview conducted. A copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Aug 17, 2021

The state marks this report as 17 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.