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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800471
Report Date: 04/14/2023
Date Signed: 04/14/2023 10:58:22 AM

Substantiated


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
04/06/2022 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220406112657
FACILITY NAME:VILLA DE ANZA ASSISTED LIVINGFACILITY NUMBER:
331800471
ADMINISTRATOR:KENNY ESPINALFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 685-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:0CENSUS: 0DATE:
04/14/2023
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director Ashley WillettTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility has pest.
Facility kitchen is in disrepair.
INVESTIGATION FINDINGS:
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On 04/14/2023 at 10:00 AM, 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 to deliver the findings on 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, observation and interviews with relevant parties. The allegation indicates that Facility has pest. LPA Brown obtained evidence to corroborate the allegation. Resident Interviews indicated they saw mice in their bedroom at Room # 117, Room # 119, Room #137. Residents' interviews revealed they saw mice running from room to room of residents. Staffs' interviews indicated they saw mice in resident's bedroom, and they also saw mice running from room to room of residents at the facility. Staffs' interviews revealed that they set up mice trap in residents' bedroom. *** Continuation in LIC9099 ***


Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
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 6
Control Number 56-AS-20220406112657
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: 04/14/2023
NARRATIVE
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During the visit last 04/08/2022, LPA Brown toured the facility with Maintenance Director Manuel Ledesma (S2) last 04/08/2022 at around 11:30 AM and LPA Brown observed mice trap at three (3) residents’ room - Room # 117, Room #103 and Room # 114 and S2 reported to LPA Brown that residents reported they saw mice in Room # 117, Room # 103, Room #114 that's why they put a mice trap. Also, during the visit last 04/08/2022, Executive Director (ED) Kenny Espinal reported to LPA Brown that the facility has a contracted exterminator that treats and addressed the mice reported at the facility. Also, during the visit last 04/08/2022, ED Espinal reported to LPA Brown that Exterminator Invoices will be provided. LPA Brown reviewed the facility's Pest Control Invoice and the facility's contracted pest control company reported that the facility needs a lot of rodent proofing and they only inspected three (3) rooms - Room #114, Room #117 and Room # 103 and they reported mice traps left. Moreover, during the visit last 04/08/2022, LPA Brown recommended to S2 that all rooms must be serviced by Exterminators not just the rooms were mice were seen. During the visit last 04/08/2022, LPA Brown explained to S2 that though the facility is taking action for the mice, as Executive Director Kenny Espinal indicated, it appears that there is not sufficient treatment being done by the facility’s contracted exterminator to aggressively rid the mice as residents also reported mice seen at Room #119 and Room # 137. S2 expressed understanding and indicated to LPA Brown that they have a plan with the contracted exterminator to address the issue which is to inspect all the residents' rooms to determine if there's a need to increase the days of the contracted exterminator from monthly to twice a month and that all resident rooms must be serviced.

The second allegation indicates Facility kitchen is in disrepair. The investigation consisted of records review and interviews with relevant parties. LPA Brown obtained evidence to corroborate the allegation. Staff interviews revealed that the hot water faucet in the kitchen sink cannot be turned off for more than a week since LPA Brown's facility visit last 04/08/2022. During the visit last 04/08/2022, LPA Brown toured the facility kitchen and observed the hot water in the kitchen faucet sink cannot be turned off and continuously pouring hot water and kitchen staffs reported to LPA Brown that the hot water kitchen faucet sink has been in disrepair for more than a week now and it's still not repaired/fixed. During the visit last 04/08/2022, LPA Brown informed ED Espinal that the hot water in the kitchen faucet sink cannot be turned off for more than a week now and ED Espinal reported to LPA Brown that the hot water kitchen faucet sink will be fixed and repaired immediately as ED Espinal will request S2 to fix/repair the issue immediately, the same day of the facility visit, 04/08/2022.

*** Continuation in LIC9099C ***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 56-AS-20220406112657
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
Section Cited
CCR
87303(a)
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87303 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 is not met as evidenced by:

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Licensee stated to submit signed Statement of Understanding on CCR 87303(a) to LPA Brown by POC due date.
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Based on interview, observations and records review, the Licensee did not comply with the section cited above by not aggressively addressing the mice issue at the facility which poses potential health, safety and personal rights risks to resident in care.
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Type B
04/21/2023
Section Cited
CCR
87303(a)
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87303 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 is not met as evidenced by:

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Licensee stated to submit signed Statement of Understanding on CCR 87303(a) to LPA Brown by POC due date.
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Based on interview, observations and records review, the Licensee did not comply with the section cited above by failure to promptly fix/repair the continuously pouring hot water faucet in the kitchen sink that lasted for more than a week which pose potential health, safety and personal rights risk to residents in care.
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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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
04/06/2022 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220406112657

FACILITY NAME:VILLA DE ANZA ASSISTED LIVINGFACILITY NUMBER:
331800471
ADMINISTRATOR:KENNY ESPINALFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 685-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:0CENSUS: 0DATE:
04/14/2023
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director Ashley WillettTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Executive Director does not treat residents with dignity or respect
INVESTIGATION FINDINGS:
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On 04/14/2023 at 10:00 AM, 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 to deliver the findings on the above allegation. 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 allegation indicates that Staff did not treat resident with dignity or respect. LPA Brown did not find evidence to corroborate the allegation. Interviews with staffs indicated that they all treat all the residents at the facility with dignity and respect. Staffs’ interviews revealed that no incident happened at the facility where a staff did not treat a resident with dignity or respect and staffs added that they treat all residents at the facility as their family. Residents’ interviews indicated that staffs are respectful to all residents and there's no incident happened at the facility where a staff did not treat a resident with dignity or respect. *** Continuation in LIC9099C ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 56-AS-20220406112657
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: 04/14/2023
NARRATIVE
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Based on the evidence, the allegation that Staff did not treat resident with dignity or respect is 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 allegation is 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 MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 56-AS-20220406112657
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: 04/14/2023
NARRATIVE
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Based on observation and interviews, the allegation of Facility has pest (Allegation #1) and Facility kitchen is in disrepair (Allegation #2) are SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted and a copy of this report, LIC9099, LIC9099D and Appeal Rights was discussed and provided to Executive Director Ashley Willett.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6