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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006192
Report Date: 10/09/2024
Date Signed: 10/09/2024 01:14:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
07/10/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240710140723
FACILITY NAME:VIOLA HOMES ESTATEFACILITY NUMBER:
306006192
ADMINISTRATOR:SNETTER, MIATTAFACILITY TYPE:
735
ADDRESS:15770 AZALEA WAYTELEPHONE:
(323) 304-4620
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:4CENSUS: 4DATE:
10/09/2024
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Stephanie Aguilar, House ManagerTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff are not providing clean linen to a client
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegations listed above. LPA was greeted and granted entry by facility staff after stating the purpose of the visit.

An initial complaint investigation visit was conducted on July 15, 2024. LPA conducted one staff and two client interviews during the visit. LPA accompanied by designated administrator later toured the facility physical plant and observed the linen and clothing storage spaces for each of the four clients in care. A copy of facility staff schedule was made. Client records for all four individuals in care were additionally requested and reviewed.

Additional interviews were conducted by telephone with multiple witnesses including the clients’ Regional Center of Orange County Service Coordinator and Quality Assurance staff.
CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
07/10/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240710140723

FACILITY NAME:VIOLA HOMES ESTATEFACILITY NUMBER:
306006192
ADMINISTRATOR:SNETTER, MIATTAFACILITY TYPE:
735
ADDRESS:15770 AZALEA WAYTELEPHONE:
(323) 304-4620
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:4CENSUS: 4DATE:
10/09/2024
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Stephanie Aguilar, House ManagerTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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2
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9
Staff are denying a client from making telephone calls
Staff did not provide safe transportation to a client
Staff are making inappropriate comments towards the client
Staff are denying a client from meeting their hygiene needs
Staff are interfering with a client's visitations
Staff did not provide adequate care and supervision
Staff are sleeping during their shift
Staff do not provide adequate laundry service for a client.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegations listed above. LPA was greeted and granted entry by facility staff after stating the purpose of the visit.

An initial complaint investigation visit was conducted on July 15, 2024. LPA conducted one staff and two client interviews during the visit. LPA accompanied by designated administrator later toured the facility physical plant and observed the linen and clothing storage spaces for each of the four clients in care. A copy of facility staff schedule was made. Client records for all four individuals in care were additionally requested and reviewed.

Additional interviews were conducted by telephone with multiple witnesses including the clients’ Regional Center of Orange County Service Coordinator and Quality Assurance staff.
CONTINUED ON FORM LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20240710140723
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VIOLA HOMES ESTATE
FACILITY NUMBER: 306006192
VISIT DATE: 10/09/2024
NARRATIVE
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CONTINUED FROM FORM LIC9099-A
Regarding the allegation that Staff are denying a client from making telephone calls, the following has been concluded: Two clients were interviewed out of four currently admitted clients, with one additional client absent at the time of the two visits and the fourth client stated to not be verbal per their Regional Center of Orange County assessment. The clients stated that they either were in possession of a personal device or that they had the ability to use the facility’s phone at their discretion. Additional witnesses denied having encountered any interference with telephone interactions with the clients, along with one witness confirming they speak with one of the clients twice a day on average.

Regarding the allegation that Staff did not provide safe transportation to a client, facility staff tasked with providing transportation were verified to be in possession of a current driver license. The facility relies on personal vehicle usage. Vehicles present on the premises during both inspections were verified to be consistent in size with the transportation of up to four clients in addition to one staff member, but not more. During the interviews with facility clients, no concerns about having to travel in vehicles in excess of their capacity were brought up.

Regarding the allegation that Staff are making inappropriate comments towards the client, the following has been concluded: Both clients interviewed denied having any concerns or complaints regarding their ongoing interactions with facility staff members. No occurrences of inappropriate comments were reported by witnesses interviewed either. The most recent unannounced visit conducted by Regional Center of Orange County staff actually concluded to the fact that clients present were satisfied with their current placement.

Regarding the allegation that Staff are denying a client from meeting their hygiene needs, the following has been concluded: Per the individual assessments as well as Individual Needs and Services Plans reviewed, facility clients do not require active assistance with toileting care and are assessed to be able to meet their own hygiene needs with support and reminders from the staff. C1 is stated to be “independent and does not need reminders to brush [their] teeth or shower” Staff was actively observed providing hygiene supplies to the clients as needed during the facility visits.

CONTINUED ON FORM LIC9099-C
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20240710140723
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VIOLA HOMES ESTATE
FACILITY NUMBER: 306006192
VISIT DATE: 10/09/2024
NARRATIVE
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CONTINUED FROM FORM LIC9099-C

Regarding the allegation that Staff are interfering with a client's visitations, the following has been concluded: None of the clients interviewed reported any complaints or concerns in receiving visitors. Identically, the latest Regional Center unannounced visit along with the documentation generated from the quarterly review of C1’s Individualized Program Plan dated March 23, 2023 states the client “is in constant contact with […] family members” and “has regular visits as well which [they] enjoy”.

Regarding the allegation that Staff did not provide adequate care and supervision, the following has been concluded: no specific instances of such a deficiency were evidenced during witnesses and clients interviews.

Regarding the allegation that Staff are sleeping during their shift, the following has been concluded: neither clients nor witnesses interviewed recalled having witnessed such circumstances either.

Regarding the allegation that Staff do not provide adequate laundry service for a client, the clients are assessed to be able to conduct their personal laundry independently with staff supervision. Based on the facility’s stated program plan, facility staff states that a specific emphasis is put on the acquisition of housekeeping skills for the clients. Interviews and facility visits were unable to corroborate instances during which inadequate reminders or assistance provided resulted in clients being unable to use clean personal articles of clothing.

Based on observation conducted during two facility visits, as well as records collected and reviewed and interviews conducted with facility staff, clients and witnesses, there is insufficient evidence to corroborate the above allegations. As a result, the allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove or refute the alleged violations occurred.

An exit interview was conducted and a copy of this report was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20240710140723
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: VIOLA HOMES ESTATE
FACILITY NUMBER: 306006192
VISIT DATE: 10/09/2024
NARRATIVE
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CONTINUED FROM FORM LIC9099
Regarding the allegation that Staff are not providing clean linen to a client, the following has been concluded: Linen for all four residents were observed during the initial investigation visit and found to appear clean. However, during a later unannounced visit conducted by Regional Center of Orange County, the bed sheets for client C1 were found to be needing to be laundered. A report of the visit conducted on September 11, 2024 was provided to the Department and processed on September 20, 2024. Facility clients are confirmed via a review of their individual assessments to be able and willing to do their own laundry. A weekly chore list was observed at the facility indicating that linen laundry is part of the clients' responsibility. However, facility staff remains responsible for providing clients with a clean and sanitary environment also.

As a result, the allegation is found to be Substantiated, meaning that the preponderance of evidence standard has been met. A type B deficiency is cited on an attached form LIC9099-D.

An exit interview was conducted. A copy of this report along with appeal rights was provided to a facility representative.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20240710140723
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: VIOLA HOMES ESTATE
FACILITY NUMBER: 306006192
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/23/2024
Section Cited
CCR
85088(c)(4)(A)
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Per CCR Section 85088(c)(4)(A) "The quantity of linen provided shall permit changing the linen at least once each week or more often when necessary to ensure that clean linen is in use by clients at all times." This requirement was not met as evidenced by:
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Linen reviewed during present visit, found to be clean. Deficiency cleared.
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Based on observation, the linen used by client C1were found to be in need of cleaning during an unannounced visit led by Regional Center of Orange County. This constitutes a potential risk to the health, safety and personal rights of individuals 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: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6