331800471-1-19-2023-56-AS-KCLS-CN9W36-20230120155524

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800471
Report Date: 01/19/2023
Date Signed: 01/19/2023 12:42:53 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
08/16/2022 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220816110752

FACILITY NAME:	VILLA DE ANZA		FACILITY NUMBER:	331800471
ADMINISTRATOR:	KENNY ESPINAL		FACILITY TYPE:	740
ADDRESS:	5881 EL PALOMINO DRIVE		TELEPHONE:	(951) 685-3333
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY:	0	CENSUS: 97	DATE:	01/19/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Katherine Trevino, Executive Director		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident’s body was infested with ants.
Staff removed residents call pendent.
Staff left resident soiled in urine and feces.
Food not provided to residents in a timely manner.

INVESTIGATION FINDINGS:

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2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above listed allegations. LPA Prieto met with Director Trevino toured facility and interviewed residents (R,. R2, R3. R4, R5, R6, R7, R8, R9, R10). Residents state that their personal and hygiene needs are being met facility staff as well as expressing that their call pendents are in working order and are carried on their person at all times. Residents stated when call pendent is pressed, staff arrive. Kitchen staff (S1) provided LPA with meal schedule and states that meals are served at the appropriate times. R11 in question was no longer at the facility and unable to interview. Facility documentation for R11, shows staff were attending to health care needs until the last day at facility.
Based on the information obtained there is not enough evidence that resident’s body was infested with ants,
staff removed residents call pendent, staff left resident soiled in urine and feces and food not provided to residents in a timely manner. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Director Trevino and a copy was left with the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 01/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023

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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