331800471-12-20-2023-18-AS-NBRN-CZ4QVN-20240102113038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800471
Report Date: 12/20/2023
Date Signed: 12/20/2023 10:41:56 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
07/19/2021 and conducted by Evaluator Mary Rico

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210719133022

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:	12/20/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Olevia Labee		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staffing is insufficient to meet the residents needs.
Residents are not getting their medications as ordered.
A resident sustained injury from malfunctioning automatic front door.
House rules aren't being enforced.
Air conditioning is not working in resident bedrooms.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Rico met with Executive Director Olevia Labeeb at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegations. LPA Rico explained the purpose of the requested Office Meeting. The investigation consisted of interviews.

For the allegation, Staffing is insufficient to meet the residents needs.

During interviews with staff, all staff stated they have met the residents’ needs. During interviews with residents, all residents stated their staff meet thier needs.

For the allegation, Residents are not getting their medications as ordered.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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-20210719133022

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VILLA DE ANZA ASSISTED LIVING	FACILITY NUMBER: 331800471
	VISIT DATE: 12/20/2023

NARRATIVE

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During interviews with staff, all staff stated they received alerts when the residents should receive their medication with the correct order. During interviews with residents, all resident stated they received their medication.

For the allegation, A resident sustained injury from malfunctioning automatic front door.

During interviews with staff, all staff stated they do not recall a resident who sustained an injury from malfunctioning automatic front door. During interviews with residents, all residents stated they are not aware of someone sustaining an injury from a malfunctioning automatic front door.

For the allegation, House rules aren't being enforced.

During interviews with staff, all staff stated they do not recall house rules for the facility. During interviews with residents, all residents were not able to provide house rules and are not aware of rules not being enforced.

For the allegation, Air conditioning is not working in resident bedrooms.

During interviews with staff, all stated they do not recall air conditioning not working in resident bedrooms. Staff stated they would report any issues to their Administrator if something needed repaired. During interviews with residents. All residents stated they do not have issues with their air conditioning.

During record review, Licensee provided all training's staff must complete before providing care.

Based on the evidence found during the investigation, the five (5) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

During today’s office meeting, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

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

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

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