<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881004
Report Date: 09/04/2025
Date Signed: 09/04/2025 05:16:49 PM

Substantiated


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
04/11/2025 and conducted by Evaluator Valerie Flores
COMPLAINT CONTROL NUMBER: 18-AS-20250411091834
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: 26DATE:
09/04/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Kathleen HylandTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff took away resident's personal items
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/04/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering complaint investigative findings into the allegation listed above. LPA Flores met with House Manager, Kailene Martinez, and explained the purpose of the visit and a tour of the facility was conducted.
It was reported staff took away Resident #1 (R1) personal items. LPA’s investigative process consisted of records review and interviews. Through record reviews, an in-house incident report detailed on 3/26/2025, Staff #1 (S1) assisted R1 with setting up R1’S computer. R1 became aggressive and allegedly threw R1 phone at S1. S1 reported they took away R1’s cellphone and computer and locked it away from R1 for safety. The facility staff did not comply with Title 22, Section 87468.1, Personal Rights of Residents in All Facilities, by S1 depriving R1 of R1’s computer and cellphone.

(Continue to LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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 5
Control Number 18-AS-20250411091834
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: 09/04/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Continuation from LIC9099)

Based on records review and interviews, the preponderance of evidence standard has been met. Therefore, the above allegation is substantiated. California Code of Regulations Title 22 is being cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report along with the LIC 9099D, and appeal rights were reviewed and provided to Administrator, Kathleen Hyland.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/11/2025 and conducted by Evaluator Valerie Flores
COMPLAINT CONTROL NUMBER: 18-AS-20250411091834

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: 26DATE:
09/04/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Kathleen HylandTIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure resident's hydration care needs were properly met
Staff did not provide activities to resident in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/04/2025, Licensing Program Analyst (LPA) Valerie Flores conducted an unannounced visit to the facility for the purpose of delivering complaint investigative findings into the allegations listed above. LPA Flores met with House Manager, Kailene Martinez, and explained the purpose of the visit and a tour of the facility was conducted.
It was alleged staff did not ensure Resident #1 (R1)’s hydration care needs were properly met by not ensuring water was readily accessible to R1. Interviews conducted with staff revealed water is provided for the residents during staff rounds as a routine. In addition, when residents request water it is provided. Staff rounds are conducted approximately every two hours. Staff further reported that if a resident was requesting water outside of the rounds, the resident can press their pendant to get staff’s attention.

(Continue to LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20250411091834
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: 09/04/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(Continuation from LIC9099)

LPA attempted to interview R1, however R1 no longer resides at the facility, and attempts to contact R1 were unsuccessful. A random sample of residents were interviewed, where 4 of 4 residents reported not having any concerns at the facility.
It was further alleged staff did not provide activities to R1. Records review of the facility’s monthly activity log was completed. The activity log divulged two activities a day are provided for the residents in care. Through staff interviews, it was reported R1 refused to participate in planned activities and preferred to stay in their room. LPA attempted to interview R1, however R1 no longer resides at the facility, and attempts to contact R1 were unsuccessful. A random sample of residents were conducted, where 3 of 4 residents reported participating in activities. The remaining interview revealed 1 of 4 reported they no longer wanted to participate in the interview; therefore, the question regarding activities was not answered.
Based on records review and interviews, the allegations are unsubstantiated. A finding that the complaint is unsubstantiated means that although the allegations may have happened and/or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.
An exit interview was conducted, and a copy of this report was reviewed and provided to Administer, Kathleen Hyland.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20250411091834
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2025
Section Cited
CCR
87468.1(a)(3)
1
2
3
4
5
6
7
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature… This requirement was not met as evidence by:
1
2
3
4
5
6
7
Administrator Kathleen Hyland will have all managing staff conduct an out-service training on residents personal right. The outside training certification along with staff signatures will be forwarded to LPA via email by Close of Business on 9/19/2025.
8
9
10
11
12
13
14
 based on records review, (1) one out of (1) one resident was not free of punishment, humiliation, intimidation, abuse, and/or other actions of a punitive nature by staff taking away resident personal items.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Valerie Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5