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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530032
Report Date: 10/03/2023
Date Signed: 10/03/2023 03:52:41 PM

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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/27/2023 and conducted by Evaluator Javier Prieto
COMPLAINT CONTROL NUMBER: 56-AS-20230927095941
FACILITY NAME:VILLA DE ANZAFACILITY NUMBER:
335530032
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 683-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:197CENSUS: 138DATE:
10/03/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Patrick McAdoo-Morton, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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#1 Staff neglected resident which resulted in pressure injury
#2 Staff left resident unattended with dry feces
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above-mentioned allegations. LPA Prieto met with administrator McAdoo-Morton and explained the elements of the visit. Regarding allegation staff neglected resident which resulted in pressure injury, LPA Prieto obtained resident #1 (R1) charting notes that reveal that R1 was not neglected as R1 was seen every, from the date of this incident on 09/26/2023, until R1's passing on 10/01/23. Staff #1 (S1) interview and records reveal that R1 did not have a pressure injury and indicated on this complaint. Facility administrator provided R1's service plan that indicate R1 diagnosis and R1's plan of care.

*** continued on LIC 9099 C ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
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 56-AS-20230927095941
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
FACILITY NUMBER: 335530032
VISIT DATE: 10/03/2023
NARRATIVE
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Regarding the allegation staff left resident unattended with dry feces, care records reveal R1 is being attended to regarding his changing and grooming needs. LPA obtained records showing R1 was attended to regarding their changing needs. Care plan reveals that R1 is assessed with a specific care need and feeding as well. Records reveal that R1's diet consist of pureed food and resident narrative notes reveal R1 was fed on the date of this incident 09/26/23.

R1 in question was not interviewed on this date as R1 passed away on 10/01/23.

Based on the information obtained there is not enough evidence that staff neglected resident which resulted in pressure injury and staff left resident unattended with dry feces. Therefore, the allegations are deemed UNSUBSTANTIATED at this time.

This report was signed by LPA Prieto and Administrator McAdoo-Morton and a copy was left with the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2