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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609872
Report Date: 11/14/2023
Date Signed: 11/14/2023 03:45:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2021 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20210216115041
FACILITY NAME:ANAVERDES VILLAFACILITY NUMBER:
197609872
ADMINISTRATOR:ESTRELLA, ERWINFACILITY TYPE:
740
ADDRESS:37335 PAINTBRUSH DRTELEPHONE:
(661) 526-7000
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 4DATE:
11/14/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Erwin Estrella, AdministratorTIME COMPLETED:
03:54 PM
ALLEGATION(S):
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Facility staff are stealing from resident.
Facility did not provide resident’s POA with proper notice of rate increase.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with the administrator, Erwin Estrella, and explained the reason for the visit.

--- Facility staff are stealing from resident

It was alleged that former facility staff stole money from Resident #1 (R1) via ATM card. To investigate the allegation on 02/25/2021, LPA Shira Stamps interviewed other parties. On 11/14/2023, LPA Duguma interviewed two (02) staff from 12:00 PM - 1:00 PM and three (03) out of four (04) residents from 1:00 PM – 2:00 PM. LPA Duguma was unable to interview one (01) out of four (04) residents. During interviews with other parties, they stated that $2,300.00 was stolen from R1 by staff and that upon speaking with the Administrator, the facility explained that the staff was terminated.
(CONT. 0n LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023
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 5
Control Number 31-AS-20210216115041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANAVERDES VILLA
FACILITY NUMBER: 197609872
VISIT DATE: 11/14/2023
NARRATIVE
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During interviews with staff, Staff #1 (S1) stated that R1 gave the former staff their ATM card of their own free will and that staff took money out thinking that it was ok because it was out of the kindness of R1’s heart, however, S1 stated that all money was returned to R1 and that the issue was resolved. Staff #2 (S2) was not employed at the time of the incident and is unaware of the allegation and did not know R1. During interviews with residents, all interviewed residents stated that their belongings have never gone missing, or any resources taken from them.
Based on interviews, there is enough information to verify the allegation, therefore, the allegation is SUBSTANTIATED at this time.
Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

--- Facility did not provide resident’s POA with proper notice of rate increase.
It was alleged that facility did not inform the Authorized Representative of the monthly rate increase. To investigate the allegation on 02/25/2021, LPA Shira Stamps requested documents. On 11/14/2023, LPA Duguma interviewed two (02) staff from 12:00 PM - 1:00 PM. Upon review of R1’s records the Admissions Agreement indicates that R1’s Authorized Representative is their daughter and facility was unable to produce proof that a letter was issued to the representative notifying them of the basic rate adjustment from $3000.00 per month to $3200.00 per month. Furthermore, the Admissions Agreement does not clearly state the average monthly rate increase or average monthly percentage increase. During interviews with staff, Staff #1 (S1) stated that the daughter is not the Authorized Representative and that the resident does not need one as R1 did not have dementia. Staff #2 (S2) was not employed at the time of the incident and is unaware of the allegation and did not know R1.

Based on record reviews and interviews, there is enough information to verify the allegation, therefore, the allegation is SUBSTANTIATED at this time.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D):

No other health and safety hazards noted during the visit.
Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20210216115041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANAVERDES VILLA
FACILITY NUMBER: 197609872
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2023
Section Cited
CCR
87217(a)
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Safeguards for Resident Cash, Personal Property, and Valuables (a)...if a resident incapable of handling his own cash resources, as documented by the initial... appraisal, is accepted for care,... cash resource shall be safeguarded in accordance with the regulations in this section.
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR Title 22 87217 Safeguards for Resident Cash, Personal Property, and Valuables The written letter must be sent to the LPA by the POC due
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This requirement is not met as evidenced by; Based on interviews&record review, Physicians Report shows R1 was incapable of handling cash resources yet facility did not safeguard R1’s cash resources which poses a potential health, safety or personal rights risk to residents in care.
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date. Note: Upon learning about the incident, Licensee reconciled by returning the stolen money in full to the resident.
Type B
11/17/2023
Section Cited
HSC
1569.655(a)
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(a) If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less than 60 days' prior written notice to the residents or the residents' representatives…
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The Licensee will review regulation and submit a written letter certifying that, moving forward, they will ensure to follow and adhere to Health & Safety Code 1569.655(a); The written letter must be sent to the LPA by the POC due date.
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This requirement is not met as evidenced by; Based on record review and interview the facility did not provide a written notification of the rate increase which is a potential health safety and personal rights risk to resident in care.
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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.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2021 and conducted by Evaluator Abeye Duguma
COMPLAINT CONTROL NUMBER: 31-AS-20210216115041

FACILITY NAME:ANAVERDES VILLAFACILITY NUMBER:
197609872
ADMINISTRATOR:ESTRELLA, ERWINFACILITY TYPE:
740
ADDRESS:37335 PAINTBRUSH DRTELEPHONE:
(661) 526-7000
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY:6CENSUS: 4DATE:
11/14/2023
UNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Erwin Estrella, AdministratorTIME COMPLETED:
03:54 PM
ALLEGATION(S):
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Staff are not obtaining timely medical treatment for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Abeye Duguma conducted an unannounced subsequent complaint visit to this facility to investigate the above allegations. LPA met with the administrator, Erwin Estrella, and explained the reason for the visit.

--- Staff are not obtaining timely medical treatment for resident.

It was alleged that staff did not seek medical attention for an injury on R1’s ear. To investigate the allegation on 11/14/2023, LPA Duguma interviewed two (02) staff from 12:00 PM - 1:00 PM and three (03) out of four (04) residents from 1:00 PM – 2:00 PM. LPA Duguma was unable to interview one (01) out of four (04) residents. During interviews with staff, Staff #1 (S1) stated that R1 scratched themselves on the ear while itching, that R1 was receiving hospice services, and they were well aware of the scratch.

(CONT. on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20210216115041
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ANAVERDES VILLA
FACILITY NUMBER: 197609872
VISIT DATE: 11/14/2023
NARRATIVE
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S1 stated that hospice services would clean the scratch, apply ointment and bandage twice a week or more if needed. During interviews with residents, all interviewed residents stated that staff provide timely medical treatment and assistance when needed.

Based on interviews, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No other health and safety hazards noted during the visit.

Exit interview conducted and a copy of the report was issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5