197602345-9-29-2021-28-AS-FFIS-C8WQ4H-20211119105023

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197602345
Report Date: 09/29/2021
Date Signed: 09/29/2021 12:16:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/22/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20210922105059

FACILITY NAME:	VILLA GARDENS		FACILITY NUMBER:	197602345
ADMINISTRATOR:	JEFFREY SIANKO		FACILITY TYPE:	741
ADDRESS:	842 EAST VILLA STREET		TELEPHONE:	(626) 796-8162
CITY:	PASADENA	STATE: CA	ZIP CODE:	91101
CAPACITY:	340	CENSUS: 214	DATE:	09/29/2021
		UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Paula Digerness - Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Residents engaged in a physical altercation while in care due to lack of supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s)(LPAs) Mary Flores and Jewel Baptiste conducted an unannounced complaint investigation visit regarding the above allegation. LPAs met with administrator Paula Digerness and explained the reason of the visit.

The visit consisted of the following: LPAs requested copies of resident and staff rosters, interviewed administrator, and wellness director. During the review of resident roster it was found that residents in question do not reside at the facility. LPAs proceeded to request a list of names of residents who had recently moved out of the facility or decease.

Based on the information gathered during this visit, the allegation is deemed UNFOUNDED.
A finding of UNFOUNDED means that the allegation is either false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted with Paula Digerness administrator and a copy of this report was provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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