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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530032
Report Date: 10/18/2023
Date Signed: 10/18/2023 04:36:28 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
10/11/2023 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20231011155555
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: 140DATE:
10/18/2023
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Patrick McAdoo-Morton, Executive DirectiveTIME COMPLETED:
04:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not meet resident's medical needs
Staff did not assist resident in a timely manner
Facility is in disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) made an unannounced visit to investigate and deliver findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Executive Director McAdoo-Morton. The investigation consisted of a facility tour, resident interviews, staff interviews, and document review.

For allegation, Staff did not meet resident's medical needs :

Interviews with resident #1 (R1) and the staff #1 (S1) revealed that the medical needs for R1 is a bed with full rails that R1 does not have a doctor's order for and is requesting the facility to provide. The facility is not required to provide a bed with full bed rails and cannot do so without a doctor's order.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
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-20231011155555
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: 10/18/2023
NARRATIVE
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For allegation, Staff did not assist resident in a timely manner :

Interviews with resident #1 (R1) and the staff #1 (S1) revealed the assistance in a timely manner had to do with an allegation that R1 presses the call pendent and staff does not reply in a timely manner. During time of inspection, the pendent was pressed and the staff responded in a timely manner. S1 interview and observation, reveals the pendents are in working order and systems registered calls without fail.

For allegation, Facility is in disrepair :

Interviews with (S1) and documents obtained revealed that the allegation of the facility being in disrepair, related to smoke detector not being operable. Interview with S1 stated that facility kitchen was alleged to have a fire, but there was no fire, hence the smoke detectors did not come on. Records reveal that the local fire department arrived to inspect the kitchen and required the stove hood to be cleaned. Service was provided and records of the cleaning services were obtained.

Overall, there was not enough evidence to collaborate the allegations listed above.

Based on evidence obtained during the investigation, the three (3) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

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

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2