Dulce Villa II

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry by Thelma Gonzalez. LPA began inspection with introduction, visit purpose and provided the facility caregiver with LPA identification and business card. Resident record review began- Three (3) records were reviewed. LPA reviewed for admission agreement, medical assessment and TB test results, consent forms, identification and emergency information, appraisal needs and service plans, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification. This facility is meeting documentation requirements. Employee records review began- Three (3) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening-1 missing and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current 05/31/2026. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The home is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 105.9 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals in the laundry area. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. (Continued on LIC809, Page 2) (Continued from LIC809, Page 1) LPA verified there is a telephone working at this location. There are no firearms stored and no bodies of water observed. Food Service- Food supply meets the of one week supply of nonperishable and 2-day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation, and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 10/08/2025. Facility is conducting emergency disaster drills monthly. Corporation is active and in good standing. Based on the information received during this visit today, there will be one (1) deficiency being cited per Title 22, Division 6 of The California Code of Regulations. This report, LIC809D and Appeal Rights was reviewed with Lorena Guillen and copies provided at the time of the exit interview.the state’s words, verbatim · CDSS document, Oct 9, 2025

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Abdoulaye Zerbo and Armando Perez conducted an unannounced visit to the facility for the purpose of conducting a required annual inspection. The LPAs were greeted by Manuelruel Ramas, notified of the purpose for the visit and were allowed to enter the facility to conduct the inspection. Licensee Mody Trupti arrived at a later time and was informed of the visit. Facility Overview: The facility is a single story building with 4 residents bedrooms, 2 staff bedrooms and 3 bathrooms. There is no gated pool and there are no firearms on the premises. Infection Control: LPAs observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in kitchen cabinet next to the fridge and inaccessible to residents. The smoke detector and carbon monoxide detector were hard wired together and operational. LPAs observed fire extinguishers to be in compliance with the department requirements and with and expiration date of 09/11/2025. LPAs observed the hot water temperature to meet requirements at 108.5°F. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Continued on LIC809-C..... Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of April 27th, 2025 and a CPR certification with the expiration date of 10-25-25 Record Review and Resident/Staff Files: LPAs reviewed files for three(3) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Four residents' files were reviewed and contained all required documentation. LPA's observed Staff, resident files, were stored in closet in the hallway and emergency food,, PPE's and water stored in the garage and the first aid kit was stored in a cabinet next to the fridge Health-Related Services/Incidental Medical Services: All residents' medications were securely locked and located in the hallway. LPAs reviewed medications for four residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 9-24-2024, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to Mody Truptithe state’s words, verbatim · CDSS document, Oct 17, 2024

Type of visit: Case Management - Other

Licensing Program Manager (LPM) Tricia Danielson and Licensing Program Analyst (LPA) Janette Romero arrived unannounced to the facility to conduct a case management visit in conjunction with a case management- deficiencies visit conducted on 3/6/2024. LPM and LPA met with Licensee Trupi Mody and explained the purpose of the visit. On 3/6/2024, a case management- deficiencies visit was conducted with Lorena Guillan - Facility Manager and LIC809D dated 3/6/2024 was issued. The LIC809D documented a deficiency for Section 87307(d)(6)- Personal Accommodations and Services. On appeal, this deficiency was dismissed as the incorrect statute was cited. The purpose of today's visit is to issue a citation with the correct statute. During today's visit, LPM, LPA and Mody discussed and developed a plan of correction for the deficiency. The attached LIC809D documents the correctly cited deficiency. An exit interview was conducted and a copy of this report was provided along Appeal Rights.the state’s words, verbatim · CDSS document, May 9, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87203 · Plan of correction due date: May 17, 2024

Fire Safety- All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidenced by: Based on observations, the Licensee did not comply with the above regulation due to a mattress blocking a back sliding glass exit door from a bedroom. This is a potential health, safety, and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, May 9, 2024

Plan of correction: LPM observed the mattress has been removed. The POC has therefore been met and the deficiency was cleared during today's visit.

Type of visit: Office

Licensing Program Analyst (LPA) Crystal Colvin and Licensing Program Manager (LPM) Tricia Danielson hosted a virtual meeting via Zoom with Licensee/Administrators Nikul Mody and Trupti Mody. This meeting was held to discuss outstanding corrections that needed to be made for deficiencies cited on 3/6/24. During this meeting, all outstanding deficiencies were cleared and letters confirming such will be provided via email and postal mail. LPA Colvin reminded Licensees/Administrators Nikul and Trupti Mody that she still needed them to submit the LIC9098 Proof of Corrections form for all corrections, in order for them to testify that information provided is correct. An exit interview was conducted with Licensees/Administrators Nikul and Trupti Mody and a copy of this report was provided via email and signature was requested.the state’s words, verbatim · CDSS document, Mar 15, 2024

Allegation investigated: Facility has a bed bug infestation

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Facility Manager Lorena Guillan. Below is a summary of the complaint investigation findings: Regarding allegation "Facility has a bed bug infestation": LPA Colvin conducted interviews with staff and resident(s) and toured the facility during today's inspection. Interviews conducted confirm that there was an issue with bed bugs in one resident room (R1), but that the facility has taken steps to elimiate the problem. Some of the steps taken include: replacing all of the furniture in R1's room, deep cleaning R1's room and other resident bedrooms, and treating R1's room with bed bug spray as well as pesticide "bombs". LPA Colvin inspected R1's bedroom and other resident bedrooms and did not observe any evidence of bed bugs currently at this location. Unsubstantiated Due to lack of evidence of the bed bugs being an ongoing issue and facility staff taking measures to rectify the problem once it was brought to their attention, the allegation of "Facility has a bed bug infestation" is UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with Facility Manager Lorena Guillan and Administrator Trupti Mody (via telephone) and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 6, 2024 · control 18-AS-20240229133536

Type of visit: Case Management - Deficiencies

During Licensing Program Analyst (LPA) Crystal Colvin's inspection at the facility to conduct an inspection. During this inspection, LPA Colvin observed the following violations which needed to be addressed: Physical Plant: During the inspection, LPA Colvin observed a cabinet near the washing facilities containing cleaning supplies, including bed bug spray, to be unlocked. Deficiency cited. LPA Colvin additionally observed a mattress in the backyard to be obstructing a exit from the building (sliding glass door). Deficiency cited. This is a violation of the facility's fire clearance and warrants an immediate civil penalty in the amount of $500, which LPA Colvin will be issuing today. LPA Colvin was unable to access a copy of the facility's Plan of Operation, as it was located in a locked staff room which was inaccessible to LPA Colvin during today's inspection (though the Administrator was able to email LPA Colvin what she needed). Licensing is to have access to all areas of the facility at any time, and inability to inspect any room/area results in a deficiency and immediate civil penalty of $500, which LPA Colvin will be assessing today. Personal Rights: During record review and interviews, it was revealed that on some occasions (including 2/11/24) that Resident One (R1) will request to make a call to family members and is denied by staff due to family requesting that the resident not call until at least 10am. LPA Colvin inquired as to if there is any documentation of this request from family, and Facility Manager Lorena Guillan denied any such records. LPA Colvin additionally reviewed R1's most recent Individual Program Plan (IPP) and did not observe any mention of this behavior or of it being deemed as inappropriate and the facility staff needing to address it in a specific way. Therefore, denying R1 from making a call when requesting to is a violation of R1's personal rights. Deficiency cited. LPA Colvin learned through interviews that R1 has been sleeping on a mattress in the living room for the last week while R1's room is being treated for bed bugs. LPA Colvin additionally observed in the daily notes for R1 that R1 has not been able to take a nap during the day, due to staff moving the mattress during the day and R1 not having a location to sleep. Deficiency cited. Based on observations made by LPA Colvin, the facility was cited deficiencies and assessed civil penalties in the amount of $1,000. An exit interview was conducted with Facility Manager Lorena Guillan and Administrator Trupti Mody (via telephone) and a copy of this report, LIC809Ds, LIC421IMs, appeal rights, and LIC9098 Proof of Corrections, was provided.the state’s words, verbatim · CDSS document, Mar 6, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(6) · Plan of correction due date: Mar 7, 2024

Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met by: Based on observations, the Licensee did not comply with the above regulation with one doorway (back sliding glass door to bedroom). This is an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2024

Plan of correction: Licensee agrees to remove mattress blocking doorway and provide LPA Colvin with photographic proof of correction. Plan of Correction due by 3/7/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87755(a) · Plan of correction due date: Mar 7, 2024

Inspection Authority of the Licensing Agency: (a) Any duly authorized officer, employee or agent of the licensing agency may...inspect the entire premise...with or without advance notice. This requirement was not met by: Based on interview and observation, the Licensee did not comply with the above regulation with one room (staff room). This is an immediate safety risk for residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2024

Plan of correction: Licensee agrees to formulate plan to ensure Licensing has access to all areas of facility at all times. Licensee to provide plan to LPA Colvin by Plan of Correction date of 3/7/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Mar 7, 2024

Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (2)...toxic substances such as...cleaning supplies and disinfectants. This requirement was not met by: Based on observation, the Licensee did not comply with the above regulation with one area of the facility (cabinet by laundry machines). This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Mar 6, 2024

Plan of correction: Licensee agrees to have staff lock the cabinet immediately as well as conduct staff training or hold house meeting on locking hazardous items at all times. Licensee to provide LPA Colvin with proof of training or meeting by Plan of Correction date of 3/7/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87307(a)(a)(B) · Plan of correction due date: Mar 7, 2024

Personal Accommodations and Services: (a) ...The following provisions shall apply: (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident... This requirement was not met by: Based on interview and observations, the Licensee did not comply with one room of the facility (living room). LPA Colvin learned that R1 has been sleeping in the living room. This is an immediate personal rights violation of R1.the state’s words, verbatim · CDSS document, Mar 6, 2024

Plan of correction: Licensee agrees to cease having R1 sleep in the living room and come up with other accomodations. Licensee to provide LPA Colvin with update on where R1 will be sleeping. Licensee to review regulation and self-certify understanding and that correction has been made. Due by Plan of Correction date of 3/7/24.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(14) · Plan of correction due date: Mar 7, 2024

Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (14) To have reasonable access to telephones, to both make and receive confidential calls.... This was not met by: Based on record review and interviews, the Licensee did not comply with the above regulation with one resident (R1). LPA Colvin learned that R1 is sometimes denied from making telephone calls to family due to time of day (8am) this is an immediate personal rights violation.the state’s words, verbatim · CDSS document, Mar 6, 2024

Plan of correction: Licensee agrees to train staff on resident rights. Licensee may consult with Inland Regional Center on this behavior if they would like to be able to address it. Licensee to provide LPA Colvin with proof of staff training by Plan of Correction date of 3/7/24.

Type of visit: Required - 1 Year

On 10/27/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met Staff, Lorena Guillen, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (4) residents present. The facility is a one story home with (6) bedrooms and (3) bathrooms and attached garage. No pools or firearms are at the facility. The residents served are elderly ages 60 and above. The facility residents are vendorized by Regional Center. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following: Infection Control: The LPA observed hand washing stations with hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan to train and follow infection control guidelines. Physical Plant: Physical plant was observed to be clean and in good repair. The indoor and outdoor areas were observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. See technical advisory note for item found unlocked. The smoke detector and carbon monoxide was operational, and the hot water temperature was recorded at 108.5F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. The facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Record Review and Resident/Staff Files: LPA reviewed staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. The listed administrator has proof of submitting an administrator's certificate. Resident files were reviewed, and possessed all required paperwork. Health Related Services/ Incidental Medical Services: All resident medication was locked in hallway closet. LPA reviewed resident medications, and found all medication was accounted for a had proper documentation and labeling. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The last fire drill was conducted 9/23/23. LPA observed emergency exits and emergency supplies. An exit interview was conducted where this report was reviewed along with technical notes were reviewed and provided to staff, Lorena Guillen.the state’s words, verbatim · CDSS document, Oct 27, 2023

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.