331800471-2-21-2023-18-AS-EMAN-CPQNAG-20230308091732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800471
Report Date: 02/21/2023
Date Signed: 02/21/2023 08:59:35 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
12/16/2021 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211216163843

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:	02/21/2023
		ANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Executive Ashley Willett		TIME COMPLETED:	09:10 AM

ALLEGATION(S):

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Facility failed to refill resident portable oxygen tank.
Facility needs repair, hole in resident ceiling due to pipe leak.
Executive Director makes false statements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melody Brown met with Executive Director Ashley Willett, a designee of Chief Executive Officer Betty Dominici at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 02/21/2023 at 08:10 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 failed to refill resident portable oxygen tank. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with staffs indicated that Resident #1 (R1) portable oxygen tank was refilled and Staff #1 (S1) showed documentation indicating that R1’s portable tank was refilled. Interviews with residents indicated that staffs are assisting in residents oxygen at the facility and no incident occurred where a staff did not assist/refill residents’ oxygen. *** 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: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

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 3

Control Number 18-AS-20211216163843

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: 02/21/2023

NARRATIVE

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The second allegation indicates that due to neglect, facility needs repair as there’s hole in R1’s ceiling due to pipe leak. During the investigation, LPA Brown did not find evidence to corroborate the allegation. The investigation consisted of observation and interviews with relevant parties. Staffs reported that the hole in R1’s ceiling was immediately repaired upon discovery due to pipe leak after a heavy rain. Residents’ interviews indicated that on incidents like having a hole in the ceiling due to pipe leak as a result of heavy rain, the facility immediately repairs it and no incident happened where the facility did not immediately address a building repair issue upon discovery. During the facility visit last 12/21/2021, S1 provided proof to LPA Brown that R1’s closet ceiling was already repaired. Moreover, S1 reported to LPA Brown that the hole in R1’s closet ceiling was repaired within 48 to 72 hours upon discovery of the pike leak due to heavy rain. On 01/26/2023, LPA Brown observed no hole in R1's closet ceiling. On 02/07/2023, LPA Brown interviewed R1’s family member and they reported that they were informed by the facility that the hole in R1’s closet ceiling's due to pipe leak was from the heavy rain and that it was immediately addressed and repaired. Due to the reported damage from heavy rain and issue being addressed promptly by the facility, LPA Brown did not find evidence of neglect by the facility as maintenance services was immediately completed within 48 to 72 hours for R1’s safety and well-being.

The third allegation indicated that Executive Director makes false statements. During the investigation, LPA Brown did not find evidence to corroborate the allegation. The investigation consisted of documents review and interviews with relevant parties. Interviews with staffs indicated that the Executive Director (ED) never made false statements to the residents or staffs. Staffs’ interviews revealed that no incident happened at the facility where ED made false statement to residents or staffs. Residents’ interviews indicated that Executive Director’s not making false statements to the residents. Residents’ interviews revealed that ED’s very straightforward and transparent to residents and staffs when providing statements and no incidents happened at the facility where the ED made false statements to residents or staffs. LPA Brown reviewed R1's Admission Agreement and LPA Brown did not find evidence to corroborate the allegation.

Based on the evidence, the allegations that Facility failed to refill resident portable oxygen tank (Allegation #1), due to neglect, facility needs repair as there’s hole in R1’s ceiling due to pipe leak (Allegation #2) and Executive Director makes false statements (Allegation #3) are UNSUBSTANTIATED.

*** Continuation in LIC9099C ***

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20211216163843

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: 02/21/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	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 Executive Director Ashley Willett.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023

LIC9099 (FAS) - (06/04)

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