VILLA DESCANSO SENIOR LIVING

Official classification

Type A

Official code

87465(h)(1)

Regulation authority

CCR

What the official deficiency says

87465(h)(5)Incidental Medical and Dental Care The following requirements shall apply to medications which are centrally stored:(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement was not met as evidenced by;Based on interviews and records review (R2) medication was transfer to a different container. This posed an immediate risk to residents in care.

Official plan of correction

The licensee stated they will have an all staff medication training. A copy will provided to LPA Rico. POC due date 6/19/2026

Deadline recorded: Jun 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87211(a)(1)

Regulation authority

CCR

What the official deficiency says

87211(a)(1) Reporting Requirements.. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by;Based on interviews and records review that licensee has not reported incidents to Community Care Licensing. This posed an immediate risk to residents in care.

Official plan of correction

The licensee stated they will complete a reporting requirement training. A copy will be provided to LPA Rico.

Deadline recorded: Jun 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

87303(a) Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by;Based on interviews and facility tour, S2 turning on the stove with a lighter, stove missing knobs and dishewasher out of service. This posed an immediate risk to residents in care.

Official plan of correction

The licensee stated they will complete the repairs, and send proof to LPA Rico. POC dute date 6/19/2026

Deadline recorded: Jun 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1 (a) (3) Personal Rights of Residents in all Facilities..Residents in all residential care facilities for the elderly shall have all of the.. rights: .To be free from punishment,. such as withholding residents’ money..This requirement was not met as evidenced by; Based on interviews and records review (S2) had access and control of R1 finances and subsequently spent R1 monies in the amount of $10,802.75. R1 did not acknowledge approval of access or expenditures. This posed an immediate risk to residents in care.

Official plan of correction

The Licensee is to refund R1 $10,802.75. POC due date 6/19/2026

Deadline recorded: Jun 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87217(b)(g)

Regulation authority

CCR

What the official deficiency says

87217(b)(g) Safeguards for Resident Cash, Personal Property, & Valuables..Every facility.. measures to safeguard residents' cash resources, personal property and valuables.. the residents receipts for all such articles or cash . entrusted to his care This requirement was not met as evidenced by; Based on interviews and records review, (S2) did not provide documents and receipts which ensure compliance with safeguarding R1 monies and expenditures. This posed an immediate risk to residents in care.

Official plan of correction

The Licensee stated they will complete a training for Safeguards for Resident Cash Personal Property & Valuables. A copy will be provided to LPA Rico. POC due date 6/19/2026

Deadline recorded: Jun 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87405(d)

Regulation authority

CCR

What the official deficiency says

87405(d) Administrator, Qualifications and Duties (d) .. is also the administrator, all requirements for an administrator shall apply. (1) Knowledge..2) Knowledge of and ability to conform to the applicable laws, rules..regulations..Thisrequirement was not met as evidenced by; Based on interviews and records review, (S2) S2 did not maintain and supervise R1 financial records. This posed an immediate risk to residents in care.

Official plan of correction

The Licensee stated they will complete a training regarding Administrator Qualifications. A copy will provided to LPA Rico. POC due date 6/19/2026

Deadline recorded: Jun 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87205(a)

Regulation authority

CCR

What the official deficiency says

87205 Accountability of Licensee Governing Body (a) The licensee..shall exercise general supervision over the affairs of the licensed facility..operation in conformance with these regulations and the welfare...This requirement was not met as evidenced by; Based on interviews and records review, Licensee representative (S2) did not exercise general supervision over the facility operations resulting in the financial abuse of R1. This posed an immediate risk to residents in care.

Official plan of correction

The Licensee stated they will complete a training regarding Accountability of Licensee Governing Body. A copy will be provided to LPA Rico. POC due date 6/19/2026

Deadline recorded: Jun 19, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having the pantry storage shelves dirty/ stains along with the dinning chairs/ bench in the main kitchen area dirty. which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2026 Plan of Correction The Administrator stated they will have the items cleaned and will send proof to LPA Rico.

Official classification

Type B

Official code

87555(b)(8)

Regulation authority

CCR

What the official deficiency says

(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by having four food cans expired since August 2025 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/03/2026 Plan of Correction The Administrator stated they will have an in-service training for all staff and send proof to LPA Rico. In addition, the four expire cans were removed from the pantry.

Official classification

Type A

Official code

87209(a)

Regulation authority

CCR

What the official deficiency says

87209(a) The use of alternate concepts, programs, services, procedures,techniques, equipment,space, personnel qualifactions or staffing ratios, or the cpnduct of experimental or demonstration projects shall not be prohibited by these regulations provided that: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by having a baby monitor without written consent from R1 which poses an immediate health, safety or personal rights risk to residents in care.

Official plan of correction

POC Due Date: 03/26/2026 Plan of Correction The Administrator removed the baby monitor and stated they will ensure to have the proper documents and approvals before installing a baby monitor.

Official classification

Type A

Official code

87405(d)(3)

Regulation authority

CCR

What the official deficiency says

87405(d)(3) Administrator - Qualifications and Duties (3) Ability to maintain or supervise the maintenance of financial and other records. Based on record review, the licensee did not comply with the section cited above by Administrator failing to maintain and supervise R1 financial records which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

The Administrator stated they conduct an in-service training. Proof of training will provided to LPA Rico. POC due date 2/20/2026.

Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(3) Personal Rights of Residents in All Facilities (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination Based on record review, the licensee did not comply with the section cited above by staff withholding R1 money which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

The Administrator stated they will have an in-service training. Proof of training will be provided to LPA Rico. POC due date 2/20/2026.

Deadline recorded: Feb 20, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87307(a)

Regulation authority

CCR

What the official deficiency says

87307(a) Personal Accommodation Services (a) Living accommodation and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accomodation and privacy for the reident, staff and other's who may reside in the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above by having (3) bedroom set up, on the second floor common area which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 04/02/2025 Plan of Correction Licensee stated they will remove the (3) bedroomset from the common area and will send proof to LPA Rico.

Official classification

Type A

Official code

87468.1(a)(3)

Regulation authority

CCR

What the official deficiency says

87468.1(a)(3) Personal Rights of Residents in All Facilities (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as.. interfering with daily living functions such as eating, sleeping, or elimination. Based on interviews, the Licensee did not comply with the section cited above by not ensuring residents are free from punishment, and intimidation which poses an immediate health, safety and personal rights risks to residents in care.

Official plan of correction

Administrator stated they will train their staff on the regulation cited and will send confirmation to LPA Rico. POC due date 2/12/2025

Deadline recorded: Feb 12, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87355(e)(1)

Regulation authority

CCR

What the official deficiency says

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance... This requirement is not met as evidenced by: Based on observation and interview, the Licensee did not comply with the section cited above by not obtaining Staff #1 (S1) criminal record clearance before allowing S1 to work at the facility since 1/10/2025 which pose immediate health, safety and personal rights risk to residents in care.

Official plan of correction

Licensee stated to not allow S1 to work at the facility without obtaining the required Criminal background clearance and submit copy of Staff Schedule and Personnel Summary Report (LIC500) to LPA Rico at Plan of Correction due date. POC due date 1/20/2025

Deadline recorded: Jan 20, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Staff #3 (S3) to perform blood glucose testing to Resident #3 (R3) which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2024 Plan of Correction Licensee stated to train all staff on CCR 87628(a) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.

Official classification

Type A

Official code

87705(c)(4)(A)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above by not scheduling a staff to work night (NOC) shift, awake and on duty due to having three (3) dementia residents which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2024 Plan of Correction Licensee stated to train all staff on CCR 87705(c)(4)(A) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.

Official classification

Type A

Official code

87705(f)(2)

Regulation authority

CCR

What the official deficiency says

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above by having two (2) gallons of paints in the backyard, not locked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/12/2024 Plan of Correction Licensee removed the two (2) gallons of paint at the backyard and locked it during the visit. Licensee stated to train all staff on CCR 87705(f)(2) and submit proof of Training Log to LPA Brown at PLan of Correction (POC) due date.

Official classification

Type B

Official code

87303(d)

Regulation authority

CCR

What the official deficiency says

(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above by not having a bedroom light in Room #1 which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction Licensee stated to install a new bedroom light in Room #1 and submit proof to LPA Brown at Plan of Correction (POC) due date.

Official classification

Type B

Official code

87307(a)(2)(B)

Regulation authority

CCR

What the official deficiency says

(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 includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above by utilizing the 2nd floor loft as bedrooms as evidenced of three (3) beds observed and one (1) large sectional also being utilized as a bed and two (2) individuals sleeping during the visit on 03/11/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction Licensee stated to train all staff on CCR 87303(d) and submit proof of staff training log to LPA Brown at Plan of Correction (POC) due date. Licensee will remove the three (3) beds observed in the 2nd floor loft and submit proof to LPA Brown at POC due date

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by having Rsident #3 (R3) and Resident #5 (R5) bed rail without written order from R3 and R5 Physician indicating the need for half bed rail for mobility which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction Licensee removed R3 and R5 bed rail during the visit. Licensee stated to submit staff training lo6 on CCR 87608(a)(3) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.

Official classification

Type B

Official code

87705(c)(5)

Regulation authority

CCR

What the official deficiency says

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by nit having an updated Physician Report for Resident #3 (R3) who has dementia which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/29/2024 Plan of Correction Licensee stated to submit a copy of R3's updated Physician Report to LPA Brown at Plan of Correction (POC) due date.

Official classification

Type B

Official code

87457(c)

Regulation authority

CCR

What the official deficiency says

87457 Pre-Admission Appraisal (c) Prior to admission of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above by not completing the required Pre-Admission Appraisal for Resident #2 (R2), Resident #3 (R3) and Resident #6 (R6) which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction Licensee stated to submit Signed Statement of Understanding on CCR 87457(c) to LPA Brown at Plan of Correction (POC) due date.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

87307 Personal Accomodation 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 is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above not having the backyard free of obstruction as LPA Brown observed glass window, old fire pit, in disrepair metal chairs and table in the backyard which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 03/22/2024 Plan of Correction Licensee stated to remove the glass window, old fire pit, in disrepair metal chairs and table in the backyard to LPA Brown at Plan of Correction (POC) date.

Official classification

Type A

Official code

87217(a)

Regulation authority

CCR

What the official deficiency says

87217(a) Safeguards for Resident Cash, Personal Property, and Valuables (a) A licensee shall not be required to handle residents' cash resources. handling his own cash resources, ..shall be safeguarded in accordance with the regulations in this section. Based on record review, the licensee did not comply with the section cited above by having access to R5 credit cards which poses which poses an immediate health, safety, or personal rights risk to persons in care.

Official plan of correction

Licensee will send proof they have read and understood the regulation. Licensee will have someone else take over R5 finances. POC due date by 10/28/2023

Deadline recorded: Oct 28, 2023. A deadline is not proof that correction was completed.