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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530032
Report Date: 07/12/2023
Date Signed: 07/12/2023 12:55:55 PM

Unfounded


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
09/09/2022 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220909075207
FACILITY NAME:VILLA DE ANZAFACILITY NUMBER:
335530032
ADMINISTRATOR:ESPINAL, KENNYFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 683-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:197CENSUS: 112DATE:
07/12/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Patrick McAdoo-Morton, Executive DirectorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
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9
Questionable death
INVESTIGATION FINDINGS:
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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 Questionable Death, records review and documentation of facility file records reveal that resident #1 (R1), in question, had fallen at the facility on 07/31/22. The fall was documented in the facility’s file notes and reported to CCL in a timely manner. R1 was sent to the hospital and subsequently returned to the facility on 8/3/2023, with Hospice care.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
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 5
Control Number 56-AS-20220909075207
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: 07/12/2023
NARRATIVE
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Facility staff continued to provide care and documented daily R1s care from 08/03/22 to 08/12/22. Records obtained from the Hospice Agency reveal that R1 was on hospice and being treated daily by the hospice agency up until R1 passed away on 8/12/22. The Licensee provided Licensing with a written death report as required.

This agency has investigated the complaint alleging questionable death violation. We have found that the complaint was UNFOUNDED, meaning that the allegations were false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

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: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
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
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
09/09/2022 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220909075207

FACILITY NAME:VILLA DE ANZAFACILITY NUMBER:
335530032
ADMINISTRATOR:ESPINAL, KENNYFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 683-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:197CENSUS: 112DATE:
07/12/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Patrick McAdoo-Morton, Executive DirectorTIME COMPLETED:
12:55 PM
ALLEGATION(S):
1
2
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9
Resident sustained a fracture while in care
Due to lack of supervision residents engaged in inappropriate interactions with each other
Staff failed to assist resident in a timely manner
Insufficient staffing to meet residents' needs
Staff leave residents unattended in soiled dirty diapers for extended periods of time
Staff failed to provide adequate food service
Staff failed to provide a safe environment for residents
Facility is not performing safety inspections
Staff failed to provide a comfortable temperature for residents
Facility is in disrepair
INVESTIGATION FINDINGS:
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Regarding the allegation that resident sustained a fracture while in care, documentation revealed that resident #1 (R1) in question, did have a fall at the facility, but no record of a fracture or that the fall occurred do to lack of care and supervision. R1 was treated upon return to the facility, which was documented.

Regarding the allegation that due to lack of supervision residents engaged in inappropriate interactions with each other, records reveal that resident #2 (R2) in question did not make inappropriate statements to other residents or engage in inappropriate behavior. Staff monitored and documented R2 behavior due to medication R2 was receiving.
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: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
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 56-AS-20220909075207
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: 07/12/2023
NARRATIVE
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Regarding the allegation the staff failed to assist resident in a timely manner, resident #3 (R3) in question was interviewed and stated that staff provide incontinence service by staff when resident pendant is pressed in a timely manner. R3 pressed pendant to demonstrate the pendant is working.

Regarding allegation that staff failed to provide adequate food service, LPA obtained food menus and observed that meals are of good quality and serving portions and meals are being served within that appropriate meal times. LPA also obtained an "always available menu" that resident's can chose from upon request.

Regarding the allegation that staff failed to provide a safe environment for residents, pertained to resident #2 (R2) making inappropriate statements to residents and staff not preventing R2 from making those statements. Records reveal that R2 did not make any such statements to residents.

Regarding allegation that facility is not performing safety inspections, pertains to facility have outdated fire extinguishers that are not fully charged. LPA toured facility and observed, and documented fire extinguishers to find that the have been documented by the State Fire Marshall to be in working order and have the proper pressure for use.

Regarding the allegation that staff failed to provide a comfortable temperature for residents, referenced resident rooms (#153, #246, #208, #214, #104, #207, #221, #219, #240, #205, #223, and #154) having broken AC units. LPA toured these rooms, tested the AC units and found to be working order with cool comfortable temperatures.

Regarding the allegation that facility is in disrepair, LPA tour all wings of the facility and all three floors and did not observe any signs of facility being disrepair. The facility is carpeted wall to wall and did not observe any cracks on floor as mentioned on the complaint details. The corridors were observed to be clean and free of clutter. LPA toured outside of facility and found it to be free of clutter.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20220909075207
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: 07/12/2023
NARRATIVE
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Regarding allegation that insufficient staffing to meet residents' needs, LPA Prieto obtained facility staff roster to see that there is sufficient staff to meet the needs of the residents.

Based on the information obtained there is not enough evidence that resident sustained a fracture while in care, due to lack of supervision residents engaged in inappropriate interactions with each other, staff failed to assist resident in a timely manner, insufficient staffing to meet residents' needs, staff leave residents unattended in soiled dirty diapers for extended periods of time, staff failed to provide adequate food service, staff failed to provide a safe environment for residents, facility is not performing safety inspections, staff failed to provide a comfortable temperature for residents and facility is in disrepair. Therefore, the allegations are 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: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5