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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530032
Report Date: 07/20/2023
Date Signed: 07/20/2023 03:56:38 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
07/12/2023 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230712132651
FACILITY NAME:VILLA DE ANZAFACILITY NUMBER:
335530032
ADMINISTRATOR:KATHERINE A. TREVINOFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 683-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:197CENSUS: 116DATE:
07/20/2023
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:TIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
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9
Facility staff did not ensure that resident has a means of calling for assistance.
INVESTIGATION FINDINGS:
1
2
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5
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7
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9
10
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12
13
Licensing Program Analyst (LPA) Javier Prieto made an unannounced visit to the facility to conduct a complaint investigation regarding the above allegations. LPA Javier met with Executive Director Patrick McAdoo Morton and discussed the purpose of the visit. The investigation consisted of direct observations and interviews with residents and staff.

Regarding the allegation of facility staff did not ensure that resident has a means of calling for assistance, records review and documentation of facility file records reveal that resident #1 (R1), in question, was interviewed and shown to have her call pendent on her person and is able to use this pendent for assistance by staff or escort to the facility dining area. Executive Director Morton, reassures that R1 has a call pendent and uses that pendent.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
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-20230712132651
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: 07/20/2023
NARRATIVE
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Based on the information obtained there is not enough evidence that facility staff did not ensure that resident has a means of calling for assistance. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.


An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Director Morton at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2