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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306000886
Report Date: 10/19/2022
Date Signed: 10/19/2022 10:17:57 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/30/2021 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20210630141636
FACILITY NAME:VILLA GARDENSFACILITY NUMBER:
306000886
ADMINISTRATOR:ROSLYN A. GRAYFACILITY TYPE:
735
ADDRESS:17846 HELENA CIRCLETELEPHONE:
(714) 289-8820
CITY:VILLA PARKSTATE: CAZIP CODE:
92861
CAPACITY:4CENSUS: 1DATE:
10/19/2022
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Roslyn GrayTIME COMPLETED:
08:50 AM
ALLEGATION(S):
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Facility staff caused bruising to resident
Facility staff inappropriately restrained resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to deliver amended findings on the above allegations. LPA was greeted and granted entry by Administrator Roslyn Gray and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, spoke with client, staff and witness as well as reviewed and obtained pertinent documentation such as training records and Individual Program Plan. Regarding the allegations that facility staff caused bruising to client and facility staff inappropriately restrained client, the investigation revealed the following: On 06/28/2021, Client 1 (C1) became aggressive with Administrator and was turning over furniture as well as screaming. Staff 1 (S1) intervened in the situation and attempted to calm the client. S1 stated using CPI techniques as trained. S1 held the clients hands down on the client's waist by himself as he was the only staff working. 911 was called and law enforcement responded. C1 was hospitalized for an assessment and Administrator set up mental health interventions next day. Per Administrator, C1 may have had bruising from the aggressive behavior initiated by client and witness states seeing bruising on the client's arms. S1 denies causing bruising or inappropriately restraining the client. CONTINUED ON LIC 9099C DATED 10/19/2022
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
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 3
Control Number 22-AS-20210630141636
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VILLA GARDENS
FACILITY NUMBER: 306000886
VISIT DATE: 10/19/2022
NARRATIVE
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Per interview with C1, S1 is not aggressive with client and the two get along. C1 denied S1 was rough with the client and client stated feeling safe at the facility and verbalized satisfaction. Per Orange County Regional Center Management, no form of restraint is currently authorized for use in adult facilities. The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20210630141636
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: VILLA GARDENS
FACILITY NUMBER: 306000886
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2022
Section Cited
CCR
80072(a)(3)
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..., each client shall have personal rights which include, but are not limited to, the following: To be free from corporal or unusual punishment, infliction of pain, humiliation.., or other actions of a punitive nature, including but not limited to: This req is not being met as evidenced by:
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Licensee to submit a plan of action to ensure client's rights are being adhered to during escalating behavior and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure C1's personal rights were adhered to. S1 used physical restraints on C1. This poses an immediate health and safety risk to residents in care.
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Type B
10/25/2022
Section Cited
CCR
80072(a)(1)
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Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:
To be accorded dignity in his/her personal relationships with staff and other persons. This req is not being met as evidenced by:
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Licensee to submit a written statement of understanding of the regulation and forward proof to LPA by POC due date.
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Based on interviews conducted, Licensee failed to ensure client was treated with dignity. Witness states client had bruising from interaction with staff. This poses a potential health and safety risk to clients 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.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3