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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881004
Report Date: 07/15/2025
Date Signed: 07/15/2025 03:22:15 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
07/09/2025 and conducted by Evaluator Debbie Palacios
COMPLAINT CONTROL NUMBER: 18-AS-20250709082910
FACILITY NAME:MIDTOWN VILLAFACILITY NUMBER:
331881004
ADMINISTRATOR:AGBISIT, MICHAELFACILITY TYPE:
740
ADDRESS:2789 RAFFERTY RD.TELEPHONE:
(951) 566-6610
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY:102CENSUS: 28DATE:
07/15/2025
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Kailene Martinez, Office ManagerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
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5
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8
9
Resident develop pressure injuries while in care.
Resident sustained unexplained injuries.
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
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9
10
11
12
13
Licensing Program Analyst (LPA) Debbie Palacios conducted an unannounced visit to the facility to initiate the investigation into the allegation listed above. LPA met with Office Manager Kailene Martinez and was informed of the purpose of the visit.

During the visit, LPA toured the facility and conducted two (2) staff interviews. LPA requested resident records, resident roster, and staff roster for review. Information obtained from records reviewed revealed Resident # 1 (R1) is not a resident at the facility. LPA conducted an interview via telephone with Administrator Kathleen Hyland who reported R1 has never resided at the facility. Administrator reported that (R1) resided at The Legacy of Hemet 2 facility. LPA conducted an interview with staff #1 (S1) and reported that R1 has never resided at the facility.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
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 2
Control Number 18-AS-20250709082910
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: MIDTOWN VILLA
FACILITY NUMBER: 331881004
VISIT DATE: 07/15/2025
NARRATIVE
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This agency has investigated the complaint alleging resident develop pressure injuries while in care and resident sustained unexplained injuries. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Debbie Palacios
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2