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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800471
Report Date: 03/08/2022
Date Signed: 04/18/2022 01:26:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
08/23/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210823084034
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:144CENSUS: 68DATE:
03/08/2022
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Executive Director Kenny EspinalTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility refused to accept resident back from hospital.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 03/08/2022 at 02:45 PM to deliver the findings for the above complaint allegation. Upon arrival, LPA Brown met with Executive Director Kenny Espinal, and LPA Brown informed Executive Director Espinal of the purpose of the visit.

The investigation consisted of file review and interviews with relevant parties. LPA Brown toured the facility, conducted interviews, and reviewed facility files. The allegation indicates facility refused to accept resident back from hospital. LPA Brown conducted interviews with resident and staffs. S1 reported to LPA Brown that the facility cannot accept R1 due to R1’s pressure injury and they do not have a skilled nurse that will treat R1's wound. S1 also added " R1’s responsible party had to make arrangements for home health to treat R1’s wound at the facility before they will accept R1 back at the facility." Per file review, LPA Brown observed that the facility did not accept R1 back from the hospital two (2) days after being notified of R1's discharged. *** Continuation on LIC9099C ***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
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-20210823084034
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: 03/08/2022
NARRATIVE
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Based on LPA Brown’s observations and interviews, the preponderance of evidence standard has been met. LPA Brown will be issuing a citation.

Based on LPA Brown's observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore, the allegation of Facility refused to accept resident back from hospital is SUBSTANTIATED. 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, LIC9099D, and Appeal Rights were discussed and provided to Executive Director Kenny Espinal.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20210823084034
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: 03/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2022
Section Cited
CCR
87224(a)
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87224 Eviction Procedures (a) The Licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required. Licensee did not meet the requirement as evidenced by:
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Licensee stated to create to review Title 22, SEction 87224(a) and write a elf certification that the regulation has been read and understood and submit Self Certification to LPA Brown by POC due date.
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Based on interviews, record review and observations, the licensee refused to accept R1 back to the facility upon hospital discharged. This posed a potential Health, Safety or Personal Rights risk to residents in care.
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CCR
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Licensee stated to review Title 22, Section 87224(a) and write a self certification that the regulation has been read and is understood. Submit Proof of correction to LPA Brown by POC due date.
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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: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3