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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800471
Report Date: 01/19/2023
Date Signed: 01/19/2023 01:21:10 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
08/05/2022 and conducted by Evaluator Javier Prieto
COMPLAINT CONTROL NUMBER: 56-AS-20220805104420
FACILITY NAME:VILLA DE ANZAFACILITY NUMBER:
331800471
ADMINISTRATOR:KENNY ESPINALFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 685-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:0CENSUS: 97DATE:
01/19/2023
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Katherine Trevino, Executive Director TIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Residents left in soiled clothing for extended periods of time
Staff are mismanaging resident medication
Staff are falsifying resident medication records
Resident rooms are not kept clean
INVESTIGATION FINDINGS:
1
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 (R1, R2, R3. R4, R5, R6, R7, R8, R9, R10). Residents state that their personal and hygiene needs are being met by facility staff as well as inspection of resident rooms to show rooms are clean. LPA Prieto interviewed Med Tech staff (S1 and S2) who explained the process of documenting the dispensing of medication to residents using a computerized program to assure medications are dispensed properly and accurately.
Based on the information obtained there is not enough evidence that residents left in soiled clothing for extended periods of time, staff are mismanaging resident medication, staff are falsifying resident medication records and resident rooms are not kept clean. 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 ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 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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