306006204-7-24-2026-22-AS-SSAS-DWHQ2G-20260731114704

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306006204
Report Date: 07/24/2026
Date Signed: 07/24/2026 09:25:11 AM

Unsubstantiated

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
06/01/2026 and conducted by Evaluator Garlli Tat

COMPLAINT CONTROL NUMBER: 22-AS-20260601123502

FACILITY NAME:	WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVING		FACILITY NUMBER:	306006204
ADMINISTRATOR:	ESPINAL, ALMA		FACILITY TYPE:	740
ADDRESS:	2025 N BUSH ST		TELEPHONE:	(714) 541-3357
CITY:	SANTA ANA	STATE: CA	ZIP CODE:	92706
CAPACITY:	130	CENSUS: 105	DATE:	07/24/2026
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Erick Gonzalez		TIME COMPLETED:	09:40 AM

ALLEGATION(S):

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Staff do not clean resident properly after using the restroom.
Staff do not treat resident with dignity and respect.
Staff did not ensure resident was fed before a medical appointment.
Staff do not allow resident to eat an alternative meal.
Staff will not allow resident to leave the dining area until everyone is finished eating.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Garlli Tat made an unannounced visit to the facility to deliver the findings on the above allegations. LPA met with the Med Tech and explained the purpose of the visit. The med tech called the Executive Director, who provided verbal consent that med tech can sign the report on her behalf.

An initial complaint investigation visit took place on June 4, 2026. During the visit, LPA accompanied by staff conducted a tour of the facility's physical plant. LPA requested and obtained the resident and staff roster, facility menu, preplacement appraisal, unusual incident/injury report dated 05/09/2026 and 05/28/2026, resident appraisal, appraisal/needs and services plan, physician’s orders, daily progress notes, admission agreement dated 02/25/2026, physician’s report dated 02/26/2026, and post acute order summary report dated 02/12/2026. Nine staff and five resident interviews were conducted during the visit. Six resident interviews were conducted in total.

The investigation revealed the following: Continued on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

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-20260601123502

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: WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVING	FACILITY NUMBER: 306006204
	VISIT DATE: 07/24/2026

NARRATIVE

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Regarding the allegation that Staff do not clean resident properly after using the restroom, it was reported that resident was accompanied to the bathroom but didn’t receive assistance. Resident (R1) had to clean themselves. Per review of physician’s report dated February 26, 2026, R1 is legally blind. Per review of preplacement appraisal information, R1 uses wheelchair, requires assistance with bathing and personal hygiene, but does not require assistance with toileting. R1 reported that staff does not assist with changing and they had to change themselves. Two out of five residents interviewed stated they are not cleaned properly after the bathroom. Three out of five residents stated they don’t need assistance with cleaning. Two out of nine staff interviewed stated that R1 verbalized he did not require assistance with cleanup after toileting. Four out of nine staff stated they do assist R1 with cleaning. Three out of nine staff provided irrelevant answers. There is no evidence supporting the allegation.

Regarding the allegation that Staff do not treat resident with dignity and respect, it was reported that resident was asked to say “please” before being provided food. R1 reported they been insulted in Spanish. Per admission agreement dated February 25, 2026, residents of residential care facilities for the elderly shall be accorded dignity in their personal relationships with staff, residents, and other persons. Two out of five residents interviewed confirmed the allegation that they are not treated with dignity and respect. Two out of five residents denied the allegation. One out of five residents did not provide an adequate answer. Eight out of nine staff denied the allegation. One out of nine staff confirmed the allegation but could not provide further information. There is no evidence supporting the allegation.

Regarding the allegation that Staff did not ensure resident was fed before a medical appointment, it was reported that resident was not provided with a snack prior to their dialysis appointment. It was reported that R1 arrived at his appointment “hungry and dirty”. Per review of R1’s admission agreement, they are provided with three nutritious meals daily and between meals nourishment or snack. The facility does not document meals received. One out of five residents interviewed stated they receive snacks before and after an appointment. Four out of five residents did not have relevant information regarding the allegation. Two out of nine staff reported at times, they are not advised to feed them depending on the appointment. Seven out of nine staff reported residents are always provided with a snack prior to appointments. There is no evidence supporting the allegation.

Regarding the allegation that Staff do not allow resident to eat an alternative meal, it was reported that resident was not brought a different meal despite asking for one. Continued on LIC9099-C.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20260601123502

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: WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVING	FACILITY NUMBER: 306006204
	VISIT DATE: 07/24/2026

NARRATIVE

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Per review of daily menu, breakfast, lunch, and dinner entrees are listed every day. Residents may request a different meal by 10:00am. If no orders are placed by that time, residents are given the “meal of the day”. Three out of five residents interviewed stated they are always provided with alternative meals. One out of five residents stated there are not a lot of options available. One out of five residents did not have anything relevant to add to the allegation. Nine out of nine staff interviewed denied the allegation. There is no evidence supporting the allegation.

Regarding the allegation that Staff will not allow resident to leave the dining area until everyone is finished eating, it was reported that resident had to remain seated until other residents were finished during mealtimes. LPA toured the dining area and observed that residents came and left as they pleased. R1 reported that some staff would allow them to leave, while some didn’t. R1 did not recall the names of the staff members who did not let him leave. Five out of five residents interviewed denied the allegation. Eight out of nine staff denied the allegation. One out of nine staff reported that some of the residents use wheelchairs and they have to wait a while until a caregiver comes to assist them. There is no evidence supporting the allegation.

Based on the evidence gathered during the investigation, the allegations are found to be Unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, and a copy of the present report was provided to the authorized representative. Appeal Rights were reviewed.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Garlli Tat
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2026

LIC9099 (FAS) - (06/04)

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