331800471-7-28-2021-18-AS-JESL-C6EV2K-20210831160315

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800471
Report Date: 07/28/2021
Date Signed: 07/28/2021 03:28:07 PM

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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2021 and conducted by Evaluator Crystal Colvin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210723105609

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: 97	DATE:	07/28/2021
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Taylor Collins - Associate Executive Director		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility is unsanitary

Facility has insects

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Crystal Colvin conducted an unannounced visit to investigate the above allegation. LPA Colvin met with Associate Executive Director Taylor Collins and advised her of the reason for the inspection. The finding is as follows:

Regarding the allegation "Facility is unsanitary": LPA Colvin conducted a tour of the facility's dining room with Associate Executive Director Taylor Collins (which was the area of concern in this allegation), and observed the majority of the dining room tables to be free of food debris and set with place settings in anticiaption for the dinner service. LPA Colvin did observe one table towards the left side of the dining room which was covered with dirty dishes and used napkins. LPA Colvin inquired as to what time meals are served at the facility, and was infromed that while there is scheduled meal times (breakfast - 7am, lunch - 11am, and dinner - 4pm), some residents like to come at the tail end of a meal period, and the facility still serves them their meals, as it is there right to eat when they choose. LPA Colvin inquired as to how long ago a resident was at this table eating, but none of the multiple staff interviewed could recall.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

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-20210723105609

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
RIVERSIDE, CA 92507

FACILITY NAME: VILLA DE ANZA ASSISTED LIVING	FACILITY NUMBER: 331800471
	VISIT DATE: 07/28/2021

NARRATIVE

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Additionally, LPA Colvin observed another table near the kitchen door which had food debris on the table (what appeared to look like bits of scrambled eggs) and large area underneath the table which had food debris/trash. As of the time of LPA Colvin's inspection, it was approximately three hours after the lunch service and less than two hours until the dinner service, yet the dining room was still in disarray (at least two tables). Lastly, when LPA Colvin and Associate Executive Director Taylor entered the kitchen to inquire with staff about the status of the dining room, no kitchen staff were in the kitchen or dining room area, and Taylor had to page for staff, who were also unable to recall how long since the residents that ate at the disheveled tables had been there. Therefore, based on observations and interviews, the allegation of "Facility is unsanitary" is SUBSTANTIATED.

Regarding the allegation "Facility has insects": LPA Colvin toured the facility's dining room and kitchen in between meal services (lunch and dinner). While inspecting the dining room, LPA Colvin observed one table (noted in previous allegation) to be covered with the dirty dishes and trash from someone's meal. LPA Colvin observed a fly on the dirty dishes, which still contained some food and liquids, and pointed out the fly to Associate Executive Director Taylor Collins as the fly moved from dish to dish. Title 22 Regulations are very clear that areas in which food is served are to be kept free from insects. Therefore, based on observations and interviews, the allegation of "Facility has insects" is SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy of all reports and forms, LIC 9099D, and appeal rights are were provided to Associate Executive Director Taylor Collins during the exit interview.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20210723105609

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
RIVERSIDE, CA 92507

FACILITY NAME: VILLA DE ANZA ASSISTED LIVING	FACILITY NUMBER: 331800471
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/06/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met by:	1 2 3 4 5 6 7	Licensee agrees to have a meeting with staff regarding responsibilites/cleaning of eating areas. Licensee may self-certify to LPA Colvin once the meeting with staff has been conducted. Additional training for staff may be advisable. Plan of Correction due 8/6/21.
	8 9 10 11 12 13 14	Based on interviews and observations, the Licensee did not comply with the above regulation with at least one room (dining room) in the facility. LPA Colvin observed two tables in dining room to have food debris and/or dirty dishes well after meal service concluded. This is a potential health violation to all residents.	8 9 10 11 12 13 14
Type B 08/06/2021 Section Cited CCR 87555(b)(27)	1 2 3 4 5 6 7	General Food Service Requirements: (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to make a dining room cleaning schedule for staff to closely follow. LPA Colvin additionally suggests for the facility to consult with an exterminator on keeping kitchen/dining areas free of insects Licensee to provide LPA Colvin with copy of cleaning schedule. Plan of Correction due 8/6/21
	8 9 10 11 12 13 14	Based on observations, the Licensee did not comply with the above regulation with at least one table (left of dining room area). LPA Colvin observed a fly on a table that had dirty dishes and other trash from a previous meal service. This is a potential health risk for all residents in care.	8 9 10 11 12 13 14

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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

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