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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208910
Report Date: 05/31/2022
Date Signed: 06/01/2022 08:32:51 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2022 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20220118082443
FACILITY NAME:VILLA HERMOSAFACILITY NUMBER:
157208910
ADMINISTRATOR:SAYSON, SHANNONFACILITY TYPE:
735
ADDRESS:10808 VILLA HERMOSA DRTELEPHONE:
(661) 203-2116
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:4CENSUS: 3DATE:
05/31/2022
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Program Director, Lester ManigqueTIME COMPLETED:
07:30 PM
ALLEGATION(S):
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Staff speaks inappropriately to resident
Staff yells at resident
INVESTIGATION FINDINGS:
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On 05/31/22, Licesning Program Analyst (LPA) L. Salazar arrived at the faciity unannounced to deliver findings on the above allegations. LPA was greeted by Staff S1, stated the purpose of the visit, and was allowed entry into the facility. COVID precautionary measures were taken at the time of entry.

During the investigation, LPA reviewed facility records that included a corrective pllan of action for Staff S3. LPA reviewed resident records that include Individual Performance Plans (IPP) for Resident R1 and Resident R2. LPA interviewed R1 and R2 and staff.

Based on the information received, the preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies are being cited on the attached 9099-D.

An exit interview was conducted with Administrator vis telephone and Staff S2. A copy of this report and appeal rights were discussed and provided to the facility. A plan of correction was developed by Administrator and reviewed with LPA.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2022 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20220118082443

FACILITY NAME:VILLA HERMOSAFACILITY NUMBER:
157208910
ADMINISTRATOR:SAYSON, SHANNONFACILITY TYPE:
735
ADDRESS:10808 VILLA HERMOSA DRTELEPHONE:
(661) 203-2116
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:4CENSUS: 3DATE:
05/31/2022
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Program Director, Lester ManigqueTIME COMPLETED:
07:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not allow resident to have a smoke break
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/31/22, Licesning Program Analyst (LPA) L. Salazar arrived at the faciity unannounced to deliver findings on the above allegations.

During the investigation, LPA reviewed facility records that included a corrective pllan of action for Staff S3. LPA reviewed resident records that include Individual Performance Plans(IPP) for Resident R1 and Resident R2. LPA interviewed R1 and R2 and staff.

Although the allegation may have happened, there is not a preponderance of evident to prove that the alleged violation occurred, therefore the allegation is unsubstantiated. Exit interview conducted and copy of report was left with licensee.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 24-AS-20220118082443
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: VILLA HERMOSA
FACILITY NUMBER: 157208910
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited
CCR
80072(a)(1)
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80072 Personal Rights
(a) ... each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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Program Director (PD) provided LPA with Corective Plan of Action (CAP) for Staff S3. CAP included (4) trainings for S3 to complete within a 14 day period. PD will send proof of training to LPA
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This requirement was not met as evidenced written documentation received from facility and audio recording from Resident R1 evidencing Staff S1 was threatening to take away a Christmas gift that was bought for Resident R1. This poses a potential risk to residents in care.
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14
Type B
06/10/2022
Section Cited
CCR
80072(c)(3)
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80072 Personal Rights
(a)...each client shall have personal rights which include, but are not limited to, the following:(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.
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Program Director will hold an all staff meeting to review Title 22 personal rights regulations. Alll staff will sign the regulation and Program Director will submit proof of signatures to LPA by POC date.
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This requirement was not met as evidenced by written and audio information received from facility and resident evidencing Staff S1 was yelling and arguing with R1 about R1's personal rights.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3