331800471-2-10-2023-18-AS-EMAN-CP9NWX-20230221095014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800471
Report Date: 02/10/2023
Date Signed: 02/10/2023 11:23:31 AM

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
11/05/2021 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211105113658

FACILITY NAME:	VILLA DE ANZA ASSISTED LIVING		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: 0	DATE:	02/10/2023
		ANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Chief Executive Officer Betty Dominici		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility staff unnecessarily calls 911 in an attempt to get resident admitted to the hospital.
Facility staff does not provide resident assistance with using the restroom.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melody Brown met with Chief Executive Officer Betty Dominici at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 02/10/2023 at 11:00 AM to deliver the findings of the above allegations. LPA Brown explained the purpose of the requested Office Visit.

The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The first allegation indicates that Facility staff unnecessarily calls 911 in an attempt to get resident admitted to the hospital. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Records review and interviews with staffs and residents indicated that no facility staff unnecessarily calls 911 in an attempt to get a resident admitted to the hospital.

*** Continuation 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: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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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Control Number 18-AS-20211105113658

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: 02/10/2023

NARRATIVE

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LPA Brown reviewed CALFIRE Patient Care Reports for Resident 1 (R1) and LPA Brown did not observe the facility or a facility staff unnecessarily calls 911 in an attempt to get R1 admitted to the hospital.
CALFIRE Patient Care Reports for R1 indicated the facility calls 911 due to R1’s medical needs and no evidence of unnecessary calls to get R1 admitted to the hospital.

The second allegation indicates that due to neglect/lack of supervision, Facility staff did not provide resident assistance with using the restroom. During the investigation, LPA Brown did not find evidence to corroborate the allegation. The investigation consisted of records review and interviews with relevant parties. Staffs reported that they are all helping residents that need assistance to the restroom and no incident happened at the facility where a resident was not helped by a staff. Residents’ interviews indicated that staffs are always helping residents that needs assistance on using the restroom and they are not aware of an incident that happened at the facility where a staff did not help a resident on using the restroom. LPA Brown reviewed records and it indicated two (2) staffs were assisting R1 to use the bathroom last 11/04/2021 but due to R1 being weak that day, R1 was unable to help the two (2) staffs with the transfer from the recliner to the wheelchair, and staff had to call for another staff to help transfer R1 and S1 arrived to help lift/transfer R1 but still staffs attempts were unsuccessful and that’s when they had to call 911 for lift assist and per records review, R1's responsible party was informed of the incident. During the facility visit last 01/27/2023, LPA Brown interviewed Staff 3 (S3) and S3 reported that S3 was one of two (2) staff that initially assisted R1 on using the restroom last 11/04/2021 and it's just that they can't lift R1 so they called for another staff for help and S3 reported that S1 arrived to help them but after multiple attempts to lift R1, even with the three (3) of them, they still can't transfer R1 from the recliner to R1's wheelchair to go the restroom. Also, S3 indicated that R1 refused to use a bedpan and insisted of not using a bedpan that’s why they had to call 911 for lift assist.

Based on the evidence, the allegation that Facility staff unnecessarily calls 911 in an attempt to get resident admitted to the hospital (allegation #1) and Facility staff did not provide resident assistance with using the restroom (allegation # 2) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time.

An exit interview was conducted where this report, LIC9099 was discussed and provided to Chief Executive Officer Betty Dominici.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC9099 (FAS) - (06/04)

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