331800471-2-17-2022-18-AS-EMAN-CCSQR2-20220323122311

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800471
Report Date: 02/17/2022
Date Signed: 02/17/2022 05:07:55 PM

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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/30/2021 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210730123000

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:	144	CENSUS: 71	DATE:	02/17/2022
		UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Executive Director Kenny Espinal		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Food service is inadequate
Staff are not providing adequate care and supervision to the residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 02/17/2022 at 04:15 PM to deliver the findings for the above complaint allegations. Upon arrival, LPA Brown met with Executive Director Kenny Espinal, toured the facility, and spoke with staff and residents in care.

The first allegation indicates Food service is inadequate. LPA Brown obtained evidence to corroborate the allegation. Interviews with residents and staffs indicated that the facility kitchen staff did not follow menu and made substitutions to the set menu because of unavailability of ingredients. Interview with the facility's dietician indicated that no information was provided and no approval was made for the reported substitution. Also, foods were either serve cold or late. Records review, staff and resident interviews revealed that insufficient food services personnel were scheduled to work to meet the resident’s needs.

***Continuation in LIC9099C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

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-20210730123000

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
RIVERSIDE, CA 92507

FACILITY NAME: VILLA DE ANZA ASSISTED LIVING	FACILITY NUMBER: 331800471
	VISIT DATE: 02/17/2022

NARRATIVE

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The second allegation indicates Staff are not providing adequate care and supervision to the residents. LPA Brown obtained evidence to corroborate the allegation. Interviews with residents and staff indicated that it takes about 30 minutes, 45 minutes, an hour or even more for a staff to assist a resident in care. 6/8 residents interviewed reported that it takes a long time for staff to assist them. Out of 9 staffs interviewed, 6 reported that the facility’s do not have enough staff to care and supervise residents in care. Records review and interviews revealed that there’s insufficient number of personnel to provide services necessary to meet the resident’s needs.

Based on LPA Brown’s observations, interviews and records review, the preponderance of evidence standard has been met, and therefore the above allegations that food service is inadequate (allegation #1), and staff are not providing adequate care and supervision to the residents(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.

An exit interview was conducted where this report (LIC9099), LIC9099D, and Appeal Rights were provided and discussed to Executive Director Kenny Espinal.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20210730123000

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
RIVERSIDE, CA 92507

FACILITY NAME: VILLA DE ANZA ASSISTED LIVING	FACILITY NUMBER: 331800471
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/17/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/24/2022 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	Licensee agrees to sufficiently staff according to residents needs, report to CCLD residents who are independent or who needs care. Also, LIcensee will have staff trained on residents needs and submt Training Log to LPA Brown by 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
Type B 03/02/2022 Section Cited CCR 87555(a)	1 2 3 4 5 6 7	87555 General Food Requirements (a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowance of the Food and Nutrition Board ...Licensee did not meet this requirement as evidenced by:	1 2 3 4 5 6 7	Licensee stated he will review regulation - CCR 87555(a) and submit a Statement of Understanding to LPA Brown by POC due date.
	8 9 10 11 12 13 14	Based on interviews, record review and observations, the licensee did not ensure that they consult or obtain Dietician's approval on the reported substitution of the menu. This poses a potential Health, Safety or Personal Rights risk to residents in care.	8 9 10 11 12 13 14	Licensee will train staff to follow set menu and create a procedure or guidelines on how to notify and seek approval from dietician if there'll be changes on menu and submit created procedure or guidelines and training log to LPA Brown by POC due date.

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 Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

LIC9099 (FAS) - (06/04)

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