Villa Board and Care Home.

“Based on observation, the licensee did not comply with the section cited above by having trash in a trash bad on the side of the house and having syringes located in an unlocked cabinet in the kitchen which poses an immediate health and safety risk to persons in care. POC Due Date: 02/26/2026 Plan of Correction 1 2 3 4 Administrator agreed to remove trash and put the sharps container in the locked cabinet and provide photos of the corrections to the department by the POC date.”

“Based on observation, the licensee did not comply with the section cited above by having a commode, 3 ladders, 3 gas cans,rake, 2 lawn mowers, broken table, wood planks, broken chairs, overgrown trees, wheelbarrow, dolly's, gulf club, 2 mattresses van, motor home and black small car all vehicles are not operable. 2 shovels, storage unit unlocked. which poses a potential health and risk to persons in care. POC Due Date: 03/11/2026 Plan of Correction 1 2 3 4 Administrator agreed to remove all items from the back and side yard, put a lock on the storage and have all the non operable vehicles moved by the POC date and submit photos to the department.”

“Based on observation and interview, the licensee did not comply with the section cited above by having a staff member living at the facility sleeping in the living room which poses a potential health and safety risk to persons in care. POC Due Date: 03/11/2026 Plan of Correction 1 2 3 4 Administrator agreed to move staff members son to a room or out of the facility by the POC date.”

“Based on observation, the licensee did not comply with the section cited above by not maintaining space in the garage and having clutters which poses a potential health and safety risk to persons in care. POC Due Date: 03/11/2026 Plan of Correction 1 2 3 4 Administrator agreed to have all clutters removed from the garage to be able to use the space for general storage space. Administrator also agrees to submit a photo of all the clutter removed from the garage by the POC date.”

“Based on observation during record review, the licensee did not comply with the section cited above by not being CPR or first aid certified and not having any staff that has a current CPR or first aid certificate which poses a potential health and safety risk to persons in care. POC Due Date: 03/11/2026 Plan of Correction 1 2 3 4 Administrator agreed to get CPR and first aid certified as well as have staff CPR and first aid trained by the POC date and submit copies of the certificate to the department.”

“Based on observation, interview and record review, the licensee did not comply with the section cited above by not having staff complete required staff trainings which poses a potential health and safety or risk to persons in care. POC Due Date: 03/11/2026 Plan of Correction 1 2 3 4 Administrator agreed to hire a CCLD approved vendor to conduct staff required trainings and submit copies of staff certificate of compleation.”

“Based on observation, the licensee did not comply with the section cited above by having an open porch area with clutters which poses a potential health and safety risk to persons in care. POC Due Date: 03/11/2026 Plan of Correction 1 2 3 4 Administrator agreed to clear the open porch area and submit photos to the department by the POC date.”

“Based on observation, the licensee did not comply with the section cited above by having clutters under the kitchen table, in the living room, entry way and back yard such as boxes of clothing, bedding, air fryer, rice cooker, wood planks, 3 ladders, bedrails, 2 ice chests, fruit picker, wheelchairs, 4 shovels, 2 lamps and an electric saw which poses a potential health and safety risk to persons in care. POC Due Date: 02/24/2025 Plan of Correction 1 2 3 4 Administrator agreed to remove all clutter under the kitchen table, in the living room, entry way and back yard such as boxes of clothing, bedding, air fryer, rice cooker, wood planks, 3 ladders, bedrails, 2 ice chests, fruit picker, wheelchairs, 4 shovels, 2 lamps and an electric saw and submit photos to the Department by the POC date.”

“Based on observation and interview, the licensee did not comply with the section cited above by not having a landline phone which poses a potential health and safety risk to persons in care. POC Due Date: 02/06/2025 Plan of Correction 1 2 3 4 Administrator agreed to get telephone service at the facility and submit the phone number to the Department by the POC date.”

“Based on observation and record review, the licensee did not comply with the section cited above by having Administrator and staff CPR certificates expired which poses a potential health and safety risk to persons in care. POC Due Date: 02/07/2025 Plan of Correction 1 2 3 4 Administrator agreed to update CPR training for all staff and submit a copy to the Department by the POC date”

“Based on LPAs observation licensee did not comply with the section cited above by staff/family sleeping in the garage in a makeshift bedroom being used for accommodation. Which poses a potential health and safety risk to residents. POC Due Date: 02/14/2025 Plan of Correction 1 2 3 4 Administrator agreed not to allow staff/family to sleep in the garage. Facility will submit a written addendum to their operating plan describing how the garage will be utilized as intended to CCLD by POC date.”

“This requirement was not met as evidenced by expired fire extinguisher which poses a potential health & safety risk to residents in care. POC Due Date: 01/24/2024 Plan of Correction 1 2 3 4 Administrator agreed to provide CCLD with a copy of purchase receipt for new fire extinguisher or service tag from fire extinguisher. Administrator also agreed to have fire extinguisher inspected annually for fire safety compliance.”

“Based on observation, the licensee did not comply with the section cited above by having the hot water temperature at 128.5 which poses an immediate health and safety risk to persons in care. POC Due Date: 01/18/2024 Plan of Correction 1 2 3 4 Administrator agreed to lower hot water heather, do a video of water being checked and submit to CCLD by POC date.”

“Based on observation, the licensee did not comply with the section cited above by having bar cleaner, stone cleaner, razor blade, mini saw, large saw, bernzomatic, propane, febreze air freshener, vitamins, syeringe, insulin, unlocked and assessable which poses an immediate health and safety risk to persons in care. POC Due Date: 01/18/2024 Plan of Correction 1 2 3 4 Administrator agreed to lock all items and make them in assessable to residents in care and submit photos to CCLD by POC date. Cleared during visit.”

“Based on observation, the licensee did not comply with the section cited above having a broken dish washer, spider webs on the walls in the living room, the living room window, and hanging from the ceiling, brown drippings coming down the wall in the living room, tables with dust, closet doors in bedroom #3 off track paperwork on dining table boxes on the floor in the passage way which poses a potential health and safety risk to persons in care. POC Due Date: 01/31/2024 Plan of Correction 1 2 3 4 Administrator agreed to repair/replace broken dish washer, and to clean spider webs on the walls in the living room, the living room window, and hanging from the ceiling, brown drippings coming down the wall in the living room, tables with dust, fix closet doors in bedroom #3 and remove paperwork on dining table and boxes on the floor in the passage way and provide CCLD with photos by POC date.”

“Based on observation, the licensee did not comply with the section cited above by having a broken knob in the 2nd bather shower, floor of the 2nd bathroom shower has stains, hair in the drain which poses a potential health and safety risk to persons in care. POC Due Date: 01/31/2024 Plan of Correction 1 2 3 4 Administrator agreed to fix broken knob in shower #2 and clean the stains and hair from the shower. and submit photos to CCLD by POC date.”

“Based on observation, the licensee did not comply with the section cited above by having syringe needles in a container in the small room next to the dining area which poses a potential health and safety risk to persons in care. POC Due Date: 01/31/2024 Plan of Correction 1 2 3 4 Administrator agreed to get rid of syringes and read and understand regulation and submit self certification to CCLD by POC date.”

“Based on observation, the licensee did not comply with the section cited above by having 2 large boxes in the door ways which poses a potential health and safety risk to persons in care. POC Due Date: 01/31/2024 Plan of Correction 1 2 3 4 Administrator agreed to move 2 large boxes out of the passageway and submit photos to CCLD by POC date.”

“Based on observation, interview and record review, the licensee did not comply with the section cited above by not renewing Administrator and staff CPR or First Aid certification which poses a potential health and safety risk to persons in care. POC Due Date: 01/31/2024 Plan of Correction 1 2 3 4 Administrator agreed to get CPR/First Aid renewed and send a copy of updated CPR/First Aid to CCLD via email by POC date.”

“Based on observation, interview and record review, the licensee did not comply with the section cited above by not having the Administrator continuing education or recertification documents which poses a potential health and safety risk to persons in care. POC Due Date: 01/31/2024 Plan of Correction 1 2 3 4 Administrator agreed to provide CCLD a copy of Administrator recertification document via email by POC date.”

“Based on interview and record review, the licensee did not comply with the section cited above by not providing staff training which poses a potential health and safety risk to persons in care. POC Due Date: 01/31/2024 Plan of Correction 1 2 3 4 Administrator agreed to read understand regulation, provide staff with training's and send a copy of self certification and training documents to CCLD by POC date.”

“Based on interview and record review, the licensee did not comply with the section cited above by not providing staff with ongoing training which poses a potential health and safety or risk to persons in care. POC Due Date: 01/31/2024 Plan of Correction 1 2 3 4 Administrator agreed to read understand regulation, provide staff with training's and send a copy of self certification and training documents to CCLD by POC date.”

“Based on observation, the licensee did not comply with the section cited above by having spider webs with a spider in the kitchen sink area which poses a potential health and safety risk to persons in care. POC Due Date: 01/31/2024 Plan of Correction 1 2 3 4 Administrator agreed to clean and remove spider and spider web from the kitchen sink area and send photo to CCLD via email by POC date.”

“Based on record review, the licensee did not comply with the section cited above not having a copy of the facilities emergency and disaster plan posted or on file which poses a potential health and safety risk to persons in care. POC Due Date: 01/31/2024 Plan of Correction 1 2 3 4 Administrator agreed to provide CCLD a copy of the facilities emergency and disaster plan via email by the POC date.”

“This requirement is not met as evidenced by: Deficient Practice Statement 1 2 3 4 Based on observation, the licensee did not comply with the section cited above in having 7-day non-perishable which poses a potential health and safety risk to persons in care. POC Due Date: 01/24/2024 Plan of Correction 1 2 3 4 Administrator agreed to purchase food (meat)and submit receipts and photos of food to CCLD by POC date.”

“87208((A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...7)Sketches, showing dimensions, of the following: This requirement was not met as evidence by: Deficient Practice Statement 1 2 3 4 Based on LPAs observation licensee did not comply with the section cited above by staff/family sleeping in the garage in a makeshift bedroom being used for accommodation. Which poses a potential health and safety risk to residents. POC Due Date: 01/31/2024 Plan of Correction 1 2 3 4 Administrator agreed not to allow staff/family to sleep in the garage. Facility will submit a written addendum to their operating plan describing how the garage will be utilized as intended to CCLD by POC date.”