331800471-11-3-2021-18-AS-EMAN-CDNS8Z-20220420133959

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331800471
Report Date: 11/03/2021
Date Signed: 11/03/2021 11:58:24 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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2021 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211028091946

FACILITY NAME:	VILLA DE ANZA ASSISTED LIVING		FACILITY NUMBER:	331800471
ADMINISTRATOR:	KENNY ESPINAL		FACILITY TYPE:	740
ADDRESS:	5881 EL PALOMINO DRIVE		TELEPHONE:	(951) 685-3333
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY:	144	CENSUS: 76	DATE:	11/03/2021
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Kenny Espinal		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility has bed bugs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams made an unannounced visit to the facility in order to initiate a complaint investigation into the above allegation. LPA Williams identified herself to Administrator, Kenny Espinal, and also discussed the purpose of the visit with Espinal. The investigation consisted of records review, direct observation, and interviews with staff and residents.

LPA Williams interviewed Staff #1 (S1) who stated that they have no knowledge of bed bugs in any residents room nor in the facility. S1 stated that the facility receives monthly pest control services from Eco Lab, who inspects areas of the facility such as the laundry room and kitchen, to which no indication of bed bugs were observed. Also, S1 stated that facility staff conduct "skin integrity" checks, in which no staff has reported anything unusual on any of the residents such as bed bug bites. LPA Williams interviewed Staff #2 (S2) who denied that the facility, nor the residents rooms, had bed bugs. S2 denied that any resident had bed bug bites nor have they observed any bed bugs in the residents bedding. LPA Williams interviewed Staff #3 (S3) who stated that they checked Resident #1's (R1's) bed and linen once it was reported that a staff member

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

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-20211028091946

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: 11/03/2021

NARRATIVE

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observed "something crawling" on R1. S3 stated that there was no bed bugs or any other insects observed on R1's bed or linen. S3 stated that R1 was observed for any bites; however, staff members did not observe any. LPA Williams attempted to interview R1 and Resident #2 (R2); however, due to their health conditions, LPA Williams was unable to retrieve consistent statements. LPA Williams inspected R1 and R2's bedroom and did not observe any bed bugs or insects on the residents' beds or linen.

Based on evidence obtained during today’s visit, LPA Williams has determined that the above allegation is UNSUBSTANTIATED; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed and a copy was provided to Espinal at the conclusion of the investigation.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021

LIC9099 (FAS) - (06/04)

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