331800471-4-18-2022-18-AS-EMAN-CDNSQ2-20220420140402

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800471
Report Date: 04/18/2022
Date Signed: 04/18/2022 01:29:28 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2021 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210823084034

FACILITY NAME:	VILLA DE ANZA ASSISTED LIVING		FACILITY NUMBER:	331800471
ADMINISTRATOR:	WILLIAM LEWALLEN		FACILITY TYPE:	740
ADDRESS:	5881 EL PALOMINO DRIVE		TELEPHONE:	(951) 685-3333
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY:	144	CENSUS: 77	DATE:	04/18/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Executive Director Kenny Espinal		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff neglect resulted in resident developing pressure injury.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 04/18/2022 at 11:30 AM to deliver the findings for the above complaint allegations. Upon arrival, LPA Brown met with Executive Director Kenny Espinal, and LPA Brown informed Executive Director Espinal of the purpose of the visit.

The investigation consisted of file review and interviews with relevant parties. LPA Brown toured the facility, conducted interviews, and reviewed facility files. The allegation indicates Staff neglect resulted in resident developing pressure injury. LPA Brown was not able to corroborate the allegation. LPA conducted interviews with residents and staffs. Interview with residents indicated that they were left with soiled, dirty, or wet diapers for a long time and that they developed pressure injury. Staff interviews reported that they heard residents’ complaint about their diaper not being changed and were left with soiled, dirty, or wet diapers for a long time and they developed pressure injury. However, interview with Hospice Nurse did not indicate pressure injury was caused by staff neglect of not changing the resident diaper for a long time. *** Continution in LIC9099C ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

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 18-AS-20210823084034

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: VILLA DE ANZA ASSISTED LIVING	FACILITY NUMBER: 331800471
	VISIT DATE: 04/18/2022

NARRATIVE

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Based on interviews and records review, the above allegation is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report (LIC9099) was discussed and provided to Executive Director Kenny Espinal.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC9099 (FAS) - (06/04)

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