198204587-8-4-2023-28-AS-FFIS-CUPQTJ-20230814122713

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204587
Report Date: 08/04/2023
Date Signed: 08/04/2023 01:51:59 PM

Unsubstantiated

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
04/02/2021 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210402143323

FACILITY NAME:	VILLA, THE		FACILITY NUMBER:	198204587
ADMINISTRATOR:	DAVID KIM		FACILITY TYPE:	740
ADDRESS:	12565 DOWNEY AVENUE		TELEPHONE:	(562) 861-6694
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY:	15	CENSUS: 10	DATE:	08/04/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	David Kim (Administrator)		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident sustained injury while in care.
Timely medical care not sought for resident.
Staff are restraining residents.
Facility staff served moldy food to residents.
Staff did not report incident to licensing agency.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with David Kim (Administrator) and explained the purpose of the visit.

During a the initial investigation on 04/08/21, LPA requested a copy of the staff and resident roster and interviewed Staff #1.

During today's visit, LPA obtained a copy of the Staff and Resident roster, toured the kitchen and food storage areas with Staff #1 and reviewed records for Residents #1, #2 and #3, interviewed Staff #1, #2 and #3 in the dining room and interviewed Residents #4 to #9 in various locations of the facility.

In regards to the allegation: Resident sustained injury while in care. Records review did not indicate an incident of Resident #1 sustaining injury while in care. Interviews with 3 of 3 Staff indicate they are not aware of Resident #1 sustaining injury. Continue to LIC9099C........

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

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 28-AS-20210402143323

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: VILLA, THE	FACILITY NUMBER: 198204587
	VISIT DATE: 08/04/2023

NARRATIVE

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Interviews with 6 of 6 Residents indicate they have never sustained an injury while in care and have never witnessed other Residents sustaining injury while in care.

In regards to the allegation: Timely medical care not sought for resident. Interviews with 3 of 3 Staff indicate Resident #1 did not sustain injury, therefore medical care was not sought. Staff also indicated if medical care is needed, Staff would immediate seek medical care for Residents. Interviews with 6 of 6 Resident also indicate that timely medical care is sought if needed.

In regards to the allegation: Staff are restraining residents. Per allegation detail, Resident #1, #2 and #3 were tied to their wheelchair or bed. Interviews with 3 of 3 Staff indicate Residents have never been tied to their beds for wheelchairs. Interviews with 6 of 6 Residents also indicate they have never been tied to the bed or a chair and never witnessed other Resident being restraint in such a way.

In regards to the allegation: Facility staff served moldy food to residents. LPA toured the kitchen and food storage areas and observed food to be of healthy quality. Interviews with 3 of 3 Staff indicate moldy food is never served to Residents. If food becomes moldy or bad then it is discarded. Interviews with 6 of 6 Residents indicate they have never been served moldy food.

In regards to the allegation: Staff did not report incident to licensing agency. Review of records indicate facility has a history of providing incident reports to the department. Interviews with Staff also indicate incident reports are sent to the department upon occurrence. Per allegation detail, incident of Resident #1 sustaining injury was not reported to the department. There is no proof of Resident #1 sustaining a foot injury while in care therefore an incident report for this alleged incident was not drawn.

Based on LPA's record review, observations and interviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted with David Kim (Administrator) and a copy of this report provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz Long	TELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023

LIC9099 (FAS) - (06/04)

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