<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800471
Report Date: 11/30/2023
Date Signed: 11/30/2023 10:46:25 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
06/01/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210601164527
FACILITY NAME:VILLA DE ANZA ASSISTED LIVINGFACILITY NUMBER:
331800471
ADMINISTRATOR:WILLIAM LEWALLENFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 685-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:0CENSUS: 0DATE:
11/30/2023
ANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director Olevia LabeebTIME COMPLETED:
10:50 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing resident with food in a timely manner.
Staff are not meeting residents needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/30/2023 at 10:00 AM, Licensing Program Analyst (LPA) Melody Brown met with Executive Director Olevia Labeeb, 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, and interviews with relevant parties. The allegation indicates that Staff are not providing resident with food in a timely manner. LPA Brown obtained evidence to corroborate the allegation. LPA Brown conducted interviews with resident and staffs. Resident #1 (R1), Resident #6 (R6), Resident #7 (R7), Resident #10 (R10), Resident #11 (R11) and Resident #12 (R12) all reported that staffs are serving their food late. In addition, interviews with Resident #2 (R2) and Resident #3 (R3) indicated that it takes a while for the staff to serve their food. *** Continuation in LIC9099C ***
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: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
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 18-AS-20210601164527
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: 11/30/2023
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
Moreover, interviews with Staff #5 (S5), Staff #8 (S8), Staff #9 (S9), and Staff #10 (S10) revealed that meals were not served on time to residents. Also, Staff #11 (S11) reported that breakfast are served after 9:00 AM for the residents that are in room service due to staff shortage.

The second allegation indicates Staff are not meeting residents needs. Interviews with R1, Resident #4 (R4), R6, R7, R8, R10, R11 all indicated that it takes one (1) hour, two (2) to three (3) hours, four (4) hours for a staff to respond to their call button for assistance. Residents interviews revealed that the facility's short staff and staff at the facility are not meeting their needs as Resident #3 (R3) and Resident #4 (R4) reported that they had to call the front desk phone to request for staff assistance as the staff takes a while for a staff to respond to their call button. Interviews with S5, Staff #6 (S6), Staff #7 (S7), S8 indicated that the facility's not meeting the needs of their residents due to lack of staff at the facility to provide care and supervision to their residents in care. Staff interviews revealed that two (2) caregivers are working to assist residents per building with multiple residents on two (2) staff or total assistance.

Based on LPA Brown’s interviews and records review, the preponderance of evidence standard has been met, and therefore the above allegation of Staff are not providing resident with food in a timely manner (Allegation #1), and Staff are not meeting residents needs (Allegation #2) are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC9099D.


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

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 18-AS-20210601164527
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: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/11/2023
Section Cited
CCR
87464(f)(3)
1
2
3
4
5
6
7
87464 Basic Services (f) Basic services shall at a minimum include: (3) Three nutritionally well-balanced meals and snacks made available daily, including low salt or other modified diets prescribed by a doctor as a medical necessity...This requirement is not met as evidenced by:
1
2
3
4
5
6
7
The Licensee stated to submit Signed Statement of Understanding on CCR 87464(f)(3) to LPA Brown at POC due date.
8
9
10
11
12
13
14
Based on interview and records review, the Licensee did not comply with the section cited above by not serving food on time to residents which pose potential health and personal rights risks to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 18-AS-20210601164527
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: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
87411 Personnel Requirements - General (a) Facility personnel shall be at all times sufficient in numbers, and competent to provide the services necessary to meet resident needs ... Licensee did not meet this requirement as evidenced by:
1
2
3
4
5
6
7
The Licensee stated to submit Signed Statement of Understanding on CCR 87411(a) to LPA Brown at POC due date.
8
9
10
11
12
13
14
Based on interviews, record review and observations, the licensee did not ensure that they have sufficient number of staff to provide the services necessary to meet the needs of the residents. This poses an immediate Health, Safety or Personal Rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 4 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
06/01/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210601164527

FACILITY NAME:VILLA DE ANZA ASSISTED LIVINGFACILITY NUMBER:
331800471
ADMINISTRATOR:WILLIAM LEWALLENFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 685-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:0CENSUS: 0DATE:
11/30/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director Olevia LabeebTIME COMPLETED:
10:50 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is overcharging resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/30/2023 at 10:00 AM, Licensing Program Analyst (LPA) Melody Brown met with Executive Director Olevia Labeeb, 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, and interviews with relevant parties. The allegation indicates that Facility is overcharging resident. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Resident Interviews indicated that there's no incident that they were overcharged at the facility. Staff #1 reported that no residents at the facility were charged of services that they are not provided.

*** Continuation on 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: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 18-AS-20210601164527
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: 11/30/2023
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
Based on interviews and records review, the allegation Facility is overcharging resident is UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, where this report (LIC9099) was discussed and provided to Executive Director Olevia Labeeb.

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

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6