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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800471
Report Date: 12/29/2022
Date Signed: 12/29/2022 04:02:02 PM

Substantiated


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
10/20/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211020094728
FACILITY NAME:VILLA DE ANZA ASSISTED LIVINGFACILITY NUMBER:
331800471
ADMINISTRATOR:KENNY ESPINALFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 685-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:0CENSUS: 0DATE:
12/29/2022
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ms. Betty Dominici TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident do not receive medication on time
Meals were not served on time to resident
INVESTIGATION FINDINGS:
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On 12/29/2022, Licensing Program Analyst (LPA) Melody Brown contacted Ms. Betty Dominici via Zoom meeting at 10:00 AM to deliver findings for the allegations listed above. LPA Brown explained the purpose of the Zoom Meeting. The investigation consisted of observation, interviews and review of pertinent documentations.

The first allegations indicates Resident do not receive medication on time. Staffs and resident interviews indicated Resident 1 (R1) did not receive prescribed medication on time. Staff 2 (S2) reported R1 was not able to perform own blood glucose testing which is a requirement before giving R1's insulin. S2 added that R1 requested S2 to do blood glucose test for R1 as R1's legally blind and unable to do it which S2 declined and S2 explained to R1 that S2 can assist R1 using the "hand over hand process" and S2 will read the blood glucose meter to R1 but S2 will not do it for R1 as S2 explained they are not allowed to use injections to residents. S2 added that R1 threw the blood glucose meter in S2's medicine cart and walked away.
***Continuation in LIC9099C ***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
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 5
Control Number 18-AS-20211020094728
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: 12/29/2022
NARRATIVE
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S2 reported that R1 was not given insulin medication as prescribed because R1 needs to perform blood glucose testing first before insulin administration. Per documents review, LPA Brown observed that R1 called 911 last 10/17/2021 at 05:51 PM for public assistance and R1 reported a diabetic problem. LPA Brown reviewed CALFIRE Patient Care Report and it indicated that upon confirmation that facility staff did not assist R1 on blood glucose testing and did not read R1's blood glucose meter, the facility delayed giving R1's insulin medication per schedule. CALFIRE performed R1's blood glucose meter reading and administered R1's insulin at 06:36 PM, which is beyond the scheduled time. Moreover, staff and resident interviews revealed that R1's insulin medication was given to R1 at around 3:30 PM, 30 minutes before dinner time everyday.

The second allegation indicates meals were not served on time to resident. Interviews with resident and staffs indicated that due to the incident occurred last 10/17/2021 with R1 unable to perform own blood glucose meter testing with staff assistance using hand over hand and S2 unable to read R1's blood glucose meter reading, it was reported that R1 meal/dinner is not served on time and R1 was served cheese sandwich and orange juice at around 7:00 PM.

Based on LPA Brown’s observations and interviews, the preponderance of evidence standard has been met, therefore the allegation Resident do not receive medication on time (Allegation #1), and the allegation Meals were not served on time to resident (allegation #2) are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099, LIC9099D, and Appeal Rights were discussed and provided to Ms. Betty Dominici.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20211020094728
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/30/2022
Section Cited
CCR
87464(f)(4)
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87464 Basic Services (f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications...This requirement is not met as evidenced by:
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Licensee stated to submit signed Statement of Understanding on CCR 87464(f)(4) to LPA Brown by POC due date.
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Based on interview and records review, the Licensee did not comply with the section cited above by not giving R1's insulin medication as prescribed by R1's physician due to R1's blood glucose not being checked that delayed the insulin administration last 10/17/2021 which pose immediate health, safety, and personal rights risk to resident in care.
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Type B
01/05/2023
Section Cited
CCR
87464(f)(3)
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87464 Basic Services (f) Basic services shall at a minimum include: (3) Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor as a medical necessity...This requirement is not met as evidenced by:
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Licensee stated to submit signed Statement of Understanding on CCR 87464(f)(3) to LPA Brown by POC due date.

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Based on interview and records review, the Licensee did not comply with the section cited above by not serving R1's dinner meal on time last 10/17/2022 due to blood glucose not being checked that delayed R1's insulin administration and failure to serve R1's dinner on time which pose potential health, safety and personal rights risk to resident 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.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
10/20/2021 and conducted by Evaluator Melody Brown
COMPLAINT CONTROL NUMBER: 18-AS-20211020094728

FACILITY NAME:VILLA DE ANZA ASSISTED LIVINGFACILITY NUMBER:
331800471
ADMINISTRATOR:KENNY ESPINALFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 685-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:0CENSUS: 0DATE:
12/29/2022
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ms. Betty Dominici TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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2
3
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9
Staff verbally aggressive to resident
No diabetic choices in facility menu
Facility is not clean and sanitary
Lack of staff
Resident received unlawful eviction
Staff do not respond to call system in timely manner
INVESTIGATION FINDINGS:
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On 12/29/2022, Licensing Program Analyst (LPA) Melody Brown contacted Ms. Betty Dominici via Zoom meeting at 10:00 AM to deliver findings for the allegations listed above. LPA Brown explained the purpose of the requested Zoom Meeting. The investigation consisted of observation, interviews and review of pertinent documentations.

The first allegations indicate Staff verbally aggressive to resident. Staffs’ interviews indicated no staff at the facility's verbally aggressive to resident. Residents’ interviews indicated no staff at the facility's verbally aggressive to resident. Residents’ interviews revealed all staff are respectful to residents in care.

The second allegation indicates No diabetic choices in facility menu. Staffs and residents’ interviews indicated there are diabetic choices in facility menu. LPA Brown interviewed kitchen staffs and they reported that there are diabetic choices in the facility menu for residents. ***Continuation in LIC9099C ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20211020094728
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: 12/29/2022
NARRATIVE
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The third allegation indicates Facility is not clean and sanitary. Residents’ interviews indicated the facility's clean and sanitary. Staffs’ interviews revealed that all staff are working together to keep the facility clean and sanitary. Housekeeping staff reported that they are cleaning and sanitizing the facility every day.

The fourth allegation indicates Lack of staff. Residents’ interviews revealed that there are adequate number of staff working at the facility. R1 reported to LPA Brown that R1 observed that S1 was able to hire additional staffs to provide care and supervision to residents in care and also indicated there's no staffing issue at the facility. Staffs interviews indicated sufficient number of staff working at the facility to cover all shifts.

The fifth allegation indicates Resident received unlawful eviction. Resident interviews revealed that no incident at the facility occurred where a resident received unlawful eviction. LPA Brown interviewed staffs and they all reported that no resident received unlawful eviction. R1 reported to LPA Brown that they did not receive unlawful eviction due to R1's hospitalization.

The sixth allegation indicates Staff do not respond to call system in timely manner. Resident interviews revealed all staff responds to residents call button/pendant within 10 to 15 minutes, sometimes 20 minutes. Residents reported that no incident happened at the facility where staff did not respond to a call system in a timely manner. Staffs’ interviews indicated they all respond to residents call button/pendant within 10 to 15 minutes and staffs reported that they all respond to residents call button/pendant to assist them no matter how busy the day was.

Based on interviews and records review, the allegation Staff verbally aggressive to resident (Allegation #1), No diabetic choices in facility menu (Allegation #2), Facility is not clean and sanitary (Allegation #3), Lack of staff (Allegation #4), Resident received unlawful eviction (Allegation #5), Staff do not respond to call system in timely manner (Allegation #6) are 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.

An exit interview was conducted, where this report (LIC9099) was discussed and provided to Ms. Betty Dominici.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5