331800471-11-30-2023-18-AS-EMAN-CYVN6S-20231226091134

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800471
Report Date: 11/30/2023
Date Signed: 11/30/2023 10:51:04 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
06/04/2021 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210604164100

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:	0	CENSUS: 0	DATE:	11/30/2023
		ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director Olevia Labeeb		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff not ordering medication in a timely manner.
Staff failed to contact authorized representative.

INVESTIGATION FINDINGS:

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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, observation and interviews with relevant parties. The first allegation indicates that Staff not ordering medication in a timely manner. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with residents indicated that they are not aware of any problems with their medicines not being delivered on time from the pharmacy and they never ran out of medicine prior to the next delivery. Interviews with staffs indicated that they are ordering residents medication in a timely manner.
*** 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: 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)

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Control Number 18-AS-20210604164100

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

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The second allegation indicates Staff failed to contact authorized representative. Interviews with residents indicated staffs are informing their family or authorized representative of all incidents happening at the facility. Staffs interview indicated they are reporting all incidents to residents family or authorized representative the same day that the incident happened.

Based on interviews and records review, the allegation Staff not ordering medication in a timely manner (Allegation #1), and Staff failed to contact authorized representative (Allegation #2) are 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 Malagon	TELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 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)

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