197610542-8-17-2026-31-AS-MGFS-DX5RHR-20260820130243

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610542
Report Date: 08/17/2026
Date Signed: 08/17/2026 02:23:04 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
06/26/2025 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20250626091834

FACILITY NAME:	CASANOVA CARE HOME		FACILITY NUMBER:	197610542
ADMINISTRATOR:	FLORES, RODERICK		FACILITY TYPE:	740
ADDRESS:	44315 CASA NOVA DR.		TELEPHONE:	(661) 206-8026
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 6	DATE:	08/17/2026
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Marilyn Marbella - Desiganted Administrator		TIME COMPLETED:	02:37 PM

ALLEGATION(S):

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Resident sustained unexplained injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Evelin Rios conducted a subsequent complaint investigation visit regarding the above allegation. LPA met with Marilyn Marbella and explained the reason for the visit.

The investigation consisted of the following:

On 7/01/25 LPA Rios conducted an initial complaint investigation visit. LPA requested a copy of the register of facility residents (LIC9020) and personnel report (LIC500). LPA conducted a physical plant tour of the facility inside and out. While conducting the physical plant tour LPA interviewed three (3) out of four (04) residents. LPA attempted to interview One (1) out of the four (04) residents. LPA Rios interviewed four (04) staff members and obtained copies of relevant documents pertinent to the investigation such as resident’s Medical Assessment, Appraisals, Unusual Incident Report. LPA also interviewed Resident #1’s (R1’s) family member. On today’s visit LPA delivered findings. (Continue LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2026

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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Control Number 31-AS-20250626091834

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CASANOVA CARE HOME	FACILITY NUMBER: 197610542
	VISIT DATE: 08/17/2026

NARRATIVE

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The investigation revealed the following:

Regarding the allegation: Resident sustained unexplained injury while in care. It is alleged R1 was observed with bruises to the left and right shoulder. Interviews conducted with residents revealed staff treat the residents with dignity and respect and are not aggressive when providing care. Interviews conducted with staff revealed staff were not aware of the cause of the bruises on R1 and did not know of R1 sustaining any falls. Interview conducted with staff revealed R1 is visited by family regularly and is also seen by Hospice staff. Documents reviewed revealed that staff keep notes of incidents/day to day of the residents. Facility notes dated: 06/20/25 note, R1 was observed with bruises, and on 6/23/25, staff noted R1 was seen by nurse and an x-ray was ordered by hospice. According to the administrator the x-ray ruled out possible fracture or dislocation. R1 was admitted to hospice on 10/17/24, no observations or conditions that may cause bruising were noted. Physician’s report dated: 3/23/22 notes R1 is non-ambulatory and no history of conditions that may cause bruising were noted. Although the allegation may have happened. There is not enough evidence to note the bruises developed due to neglect or abuse. Therefore, the allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies observed during this visit. Exit interview conducted and a copy of this report was provided administrator designee.

SUPERVISORS NAME: Mary G Flores
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2026

LIC9099 (FAS) - (06/04)

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