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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204587
Report Date: 05/15/2025
Date Signed: 05/15/2025 04:29:47 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
05/06/2025 and conducted by Evaluator Luis DeLeon
COMPLAINT CONTROL NUMBER: 28-AS-20250506090808
FACILITY NAME:VILLA, THEFACILITY NUMBER:
198204587
ADMINISTRATOR:DAVID KIMFACILITY TYPE:
740
ADDRESS:12565 DOWNEY AVENUETELEPHONE:
(562) 861-6694
CITY:DOWNEYSTATE: CAZIP CODE:
90242
CAPACITY:15CENSUS: 13DATE:
05/15/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator David KimTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff handled resident in care in a rough manner
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Luis De Leon and Mary Flores conducted an unannounced complaint investigation visit for the allegation listed above. LPAs met with the Administrator David Kim and explained the reason for the visit.

The investigation consisted of the following: On today’s visit, LPAs Flores, and De Leon obtaining resident and staff rosters, resident #1(R1) admission agreements, physician’s report, staff training, needs and service plan, resident appraisal, order summary report staff’s personal right training provided on 11/22/22, 3/18/08, 10/11/17, and 12/29/16. LPAs review four (4) out (4) staff records and R1’s records. LPAs interviewed five (5) out of thirteen (13) residents and four (4) out of (4) staffs. LPA contacted R1’s responsible party over the phone.

(Continue on LIC-9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Luis DeLeonTELEPHONE: (650) 388-2299
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
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 2
Control Number 28-AS-20250506090808
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VILLA, THE
FACILITY NUMBER: 198204587
VISIT DATE: 05/15/2025
NARRATIVE
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The investigation revealed the following: Regarding allegation: Staff handled resident in care in a rough manner. It is alleged that, on or around May 3rd, 2025, an individual took a resident into a room, beat the resident, and staff have treating the resident roughly. During residents’ interview, four (4) out five (5) residents stated that staff has treated them with respect and that staff are very nice to residents. Staff interviews revealed that four (4) out of four (4) staff have not been rough to residents. Three (3) out of four (4) staff described providing services to residents and stated that they treat them as if they were family. R1’s responsible party stated that has notice a change of condition on R1’s cognitive skills.

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

Exit interview was held with Administrator David Kim. A copy of the report was provided.

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Luis DeLeonTELEPHONE: (650) 388-2299
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2