335530032-7-3-2023-56-AS-EMAN-CVUMYL-20230920100139

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 335530032
Report Date: 06/20/2023
Date Signed: 07/03/2023 01:25:19 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
09/08/2022 and conducted by Evaluator Mary Rico

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220908140719

FACILITY NAME:	VILLA DE ANZA		FACILITY NUMBER:	335530032
ADMINISTRATOR:	ESPINAL, KENNY		FACILITY TYPE:	740
ADDRESS:	5881 EL PALOMINO DRIVE		TELEPHONE:	(951) 683-3333
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY:	197	CENSUS: 115	DATE:	06/20/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Patrick Mcdoomorton		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility has pests

INVESTIGATION FINDINGS:

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*** Amendment report from 6/20/2023. From substantiated to unsubstantiated report on 7/3/2023***
Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to the facility to investigate and deliver findings for the above complaint allegation. LPA met with Administrator Patrick Mcdoo-Morton and explained the reason for the visit. The visit consisted of interviews, document review, and a facility tour.

For allegation, Facility has pests.

During interviews with residents, the residents did not indicate there were pests in the facility. Residents have not seen pests in their room.

During interviews with staff, the staff did not indicate that there were pests in the facility. Staff have not seen pests inside resident's room.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20220908140719

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VILLA DE ANZA	FACILITY NUMBER: 335530032
	VISIT DATE: 06/20/2023

NARRATIVE

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*** Amendment report from 6/20/2023. From substantiated to unsubstantiated report on 7/3/2023***

The Administrator did informed LPA Rico that on 5/25/2023 they had a pest control for room 214 due to cockroaches. R1 was located from 214 to 219 until room was ready. In addition, the Administrator stated the facility have monthly pest control.

During document review, LPA discovered that the facility contracted a company for pest control. The facility took necessary steps to ensure the rooms were maintain clean and sanitized for residents.

During facility tour LPA did not witness any pest in the facility.

Based on the evidence found during the investigation, the one (1) allegation listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Administrator Patrick McAdoo-Morton, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Mary Rico	TELEPHONE: (951) 248-0293
LICENSING EVALUATOR SIGNATURE:	DATE: 07/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2023

LIC9099 (FAS) - (06/04)

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