306000560-5-31-2024-22-AS-AJLO-D6CTVK-20240618150403

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000560
Report Date: 05/31/2024
Date Signed: 05/31/2024 10:18:46 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/19/2024 and conducted by Evaluator Dwayne L Mason

COMPLAINT CONTROL NUMBER: 22-AS-20240419162936

FACILITY NAME:	GARDEN VILLA		FACILITY NUMBER:	306000560
ADMINISTRATOR:	MARILES BORJA		FACILITY TYPE:	735
ADDRESS:	13031-13061 WILSON STREET		TELEPHONE:	(714) 537-1545
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92844
CAPACITY:	32	CENSUS: 30	DATE:	05/31/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator - Mariles Borja, Administrator-in-Training - Dennis Mendoza and Secretary - Robert Mango		TIME COMPLETED:	10:35 AM

ALLEGATION(S):

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Facility staff is behaving inappropriately with client in care

INVESTIGATION FINDINGS:

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This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to conclude this agency’s investigation in the complaint allegation(s) mentioned above. LPA arrived at the facility and was greeted by Robert Mango, Secretary. LPA met with Secretary, Dennis Mendoza, Administrator-in-Training and Mariles Borja, Administrator and explained the nature of the inspection.

The department received a complaint on 4/19/2024 alleging facility staff is behaving inappropriately with a client in care. The Reporting Party (RP) disclosed that a staff member attempted to open a bathroom door while Client 1 was utilizing it. During the investigation, the department interviewed Administrator, staff and clients in care.

(continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

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 22-AS-20240419162936

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GARDEN VILLA	FACILITY NUMBER: 306000560
	VISIT DATE: 05/31/2024

NARRATIVE

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(continued from LIC9099)

On 4/25/2024 LPA conducted interviews at the facility with Administrator (AD), staff and clients in care. AD and Staff 1 and 2 denied the allegation. Interviews were conducted with Clients 2, 3 and 6 who denied experiencing facility staff walk in on them in the bathroom and did not corroborate the allegation.

LPA obtained copies of the following client files for Clients 1, 2, 3, 6 and 7: Admission Agreements and physician's reports. LPA obtained copies of the following staff files: personnel reports and statements acknowledging requirement to report suspected abuse (SOC341A).

On 5/9/2024 LPA returned to the facility and conducted interviews with Staff 3 and clients in care. Staff 3 did not corroborate the allegation. Interviews were conducted with Clients 4, 5 and 7 who denied experiencing facility staff walk in on them in the bathroom and did not corroborate the allegation.

On 5/23/2024, LPA interviewed Client 1. Client 1 corroborated the allegation.

On 5/30/2024, LPA conducted interviews with Staff 1, 2 and 3. S1, S2 and S3 stated bathroom doors do not have locks on them, all staff knock and wait for clients to respond before entering bathrooms and that no clients had stated any staff have walked in on them in the bathroom without knocking or when the clients did not need help.

Due to conflicting information received during interviews conducted, LPA was unable to determine if staff behaved inappropriately with a client. Based on interviews conducted and records reviewed there is insufficient evidence to support the allegation. Although the allegation(s) may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and this report was reviewed with Administrator, Administrator-in-Training and Secretary. A copy of this LIC-9099 was provided to the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024

LIC9099 (FAS) - (06/04)

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