306001339-1-29-2024-22-AS-AORZ-CZYNTR-20240130094508

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306001339
Report Date: 01/29/2024
Date Signed: 01/29/2024 09:17:05 AM

Unsubstantiated

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
12/01/2023 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20231201154934

FACILITY NAME:	ELEGANT CARE VILLA		FACILITY NUMBER:	306001339
ADMINISTRATOR:	DAVIDSON ALIPIO		FACILITY TYPE:	740
ADDRESS:	12712 ADAMS STREET		TELEPHONE:	(714) 901-1274
CITY:	GARDEN GROVE	STATE: CA	ZIP CODE:	92845
CAPACITY:	6	CENSUS: 3	DATE:	01/29/2024
		UNANNOUNCED	TIME BEGAN:	08:55 AM
MET WITH:	David Alipio		TIME COMPLETED:	09:35 AM

ALLEGATION(S):

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Staff took an undressed photo of resident
Staff threw a trash can at resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, the Department interviewed clients, witnesses and staff as well as reviewed and obtained pertinent documentation such as Individual Program Plans. Regarding the allegations that staff took an undressed photo of resident and staff threw a trash can at resident, the investigation revealed the following:
On 11/27/2023, Day Program Staff observed discoloration on Resident 1’s (R1) knee. Resident stated that Staff 1 (S1) had thrown a trash can at their knee ten times as well as taken an undressed photo of the resident. Upon the Department’s interview with R1, R1 denied the allegations and then later changed the allegation to the trash can being thrown only one time. R1 denied any previous abuse from the staff and states the staff is a CONTINUED ON LIC 9099C DATED 1/29/2024

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

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-20231201154934

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: ELEGANT CARE VILLA	FACILITY NUMBER: 306001339
	VISIT DATE: 01/29/2024

NARRATIVE

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friend whom they like. R1 stated the incident was unwitnessed. The Department reviewed S1’s camera and found there were no pictures of the resident on the camera. S1 reported they never shower R1 without a female staff present. This was confirmed by the facility Administrator. S1 reported the bruise on the knee occurred during transfer in the shower and denied both allegations made.
R1’s Regional Center Service Coordinator reported they have been working with R1 for twelve years and the resident denied all allegations during their interview. Interviews conducted confirm R1 has a long history of false allegations. Resident’s Individual Program Plan dated 03/16/2023 indicates a diagnosis of Psychiatric Disorder as well as a history of making false statements.

Two out of two additional residents at the facility interviewed denied any physical or sexual abuse occurring at the facility and both verbalized feeling safe at the facility. Based on records reviewed and interviews conducted, the Department is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted, and a copy of this report was provided to facility.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly Lyman	TELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024

LIC9099 (FAS) - (06/04)

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