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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005368
Report Date: 11/22/2022
Date Signed: 11/22/2022 10:56:01 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
11/04/2022 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221104165850
FACILITY NAME:SANTA AVILA CARE VILLAFACILITY NUMBER:
306005368
ADMINISTRATOR:ALIPIO, DIVINA JOY M.FACILITY TYPE:
735
ADDRESS:5501 MEINHARDT RDTELEPHONE:
(657) 352-8841
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:4CENSUS: 4DATE:
11/22/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH: Divina Alipio - Administrator TIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff is restricting a client's access to their personal storage area
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst(LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA identified themselves and were met with Divina Alipio, Administrator.

On this day, LPA delivered complaint findings. On 11/14/2022 LPA interviewed Administrator Divina Alipio via telephone who indicated Client 1 (C1) started to defecated in their closest since admission in 2018. Administrator reported that they placed a lock on C1's closet to prevent C1 from using the closet as a restroom. Staff 1 (S1) reported that C1 needs assistance while using the restroom due to their behaviors of playing with their stool. Individual Program Plan (IPP) dated 02/24/2022 does not indicate this behavior and facility has not applied for an exception.


CONT on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
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-20221104165850
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: SANTA AVILA CARE VILLA
FACILITY NUMBER: 306005368
VISIT DATE: 11/22/2022
NARRATIVE
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Therefore based on the preponderance of evidence based on observation and interviews the allegation staff is restricting a client's access to their personal storage area is SUBSTANTIATED, meaning the complaint allegation as valid and that a violation has occurred.

Based on above findings deficiencies are being cited per California Code of Regulations Title 22 Division 6 Chapter 8.

An exit interview conducted and a copy of this report was left at the facility as well as appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20221104165850
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: SANTA AVILA CARE VILLA
FACILITY NUMBER: 306005368
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/20/2022
Section Cited
CCR
85072(b)(8)
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85072 Personal Rights
(b) The licensee shall insure that each client is accorded the following personal rights.
(8) To have access to individual storage space for his/her private use.
This is not met as evidence by facility placing a lock on client 1's closet.
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Licensee corrected prior to visit.
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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: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3