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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800471
Report Date: 06/14/2021
Date Signed: 06/14/2021 03:44:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:VILLA DE ANZA ASSISTED LIVINGFACILITY NUMBER:
331800471
ADMINISTRATOR:WILLIAM LEWALLENFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 685-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:144CENSUS: 95DATE:
06/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:William Lewallen - Executive DirectorTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced after conducting a COVID-19 Risk Assessment call via telephone with the facility for the purpose of investigating a complaint (#18-AS-20210609144620). During today's inspection, LPA Colvin observed the following:

While reviewing approximately 15 resident records, LPA Colvin observed at least three resident records (R1. R2. & R3) which did not have a current Admissions Agreement for the facility. R1, R2, and R3 have lived at this location since it was previously licensed as a Brookdale facility. The change between ownership for the facility (to now being Villa De Anza Assisted Living) occurred over two years ago in March 2019. The facility has had more than enough time to ensure every resident (especially those already present at the time of licensing) have signed a new Admissions Agreement that is valid with the current facility. Due to the length of time since the facility received their license as well as the number of residents in comparison to the amount of files LPA Colvin reviewed (approximately 20% needing new Admissions Agreements), LPA Colvin will be citing a deficiency.

Additionally, LPA Colvin observed that R3 did not have a current Needs & Services Plan for this facility. R3's last Needs & Services Plan was done in 2014. LPA Colvin compared the Physician's Reports for R3 from 2014 and 2020, and observed numerous changes to the identified needs from what the physician assessed on the form. LPA Colvin additionally observed that R3 had a fall recently, which could additionally be a sign that R3 needs to be re-evaluated by the facility for their needs in order to ensure they are identified and being met. The Administrator was able to find an assessment for R3 in the facility's electronic records from 1/31/21, however, the Needs & Services Plan was never completed as the individual who did the assessment for R3 no longer works at the facility. Due to the length in time since R3 has been assessed by the facility for a Care Plan as well as the readily identifiable differences documented in R3's condition from 2014 to now, LPA Colvin is citing a deficiency.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VILLA DE ANZA ASSISTED LIVING
FACILITY NUMBER: 331800471
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2021
Section Cited

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Admissions Agreement: (a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement was not met by:
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 Based on record review, the Licensee did not comply with the above requirements in at least three resident files (R1, R2, & R3). The facility changed owners/licenses over two years ago yet three residents do not have a current Admissions Agreement for this facility in their file. This is a potential personal rights violation.
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Licensee may self-certify once both tasks are complete. Self-Certification to be submitted to LPA Colvin by Plan of Correction date of 6/28/21.
Type B
06/28/2021
Section Cited

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Documentation and Support: Each facility shall document in writing the findings of the pre-admission appraisal and any reappraisal or assessment which was necessary in accordance with Sections 87457...and 87463, Reappraisals... This requirement was not met as evidenced by:
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Based on record review, the Licensee did not comply with the above requirement in at least one resident file (R3). R3 has no current Needs & Services Plan for this facility, and the last Plan in R3's file is from 2014. R3's recent medcial records show several changes since 2014. This is a potential health risk to R3.
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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.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLA DE ANZA ASSISTED LIVING
FACILITY NUMBER: 331800471
VISIT DATE: 06/14/2021
NARRATIVE
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Due to LPA Colvin's observations, deficiencies were cited. An exit interview was conducted, and a copy of this report and appeal rights was provided to Executive Director William Lewallen.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3