335530032-2-16-2023-56-AS-KCLS-CP5T4T-20230217132427

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 335530032
Report Date: 02/15/2023
Date Signed: 02/16/2023 09:28:15 AM

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
09/13/2022 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20220913092933

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: 92	DATE:	02/15/2023
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Katherine Trevino, Director		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff are not ensuring that resident's showering needs are being met
Staff are not ensuring that resident's laundry needs are being met.
Staff are not ensuring that resident is taking their medication(s) as prescribed by their physician
Staff are not according privacy to resident

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 and met with Director Trevino to discuss the elements of the complaint. Documentation obtained, staff interviews and client #1 (C1) in question interview reveal that staff are ensuring that C1 showering needs are being met and scheduled despite C1 refusal to have those showering needs performed. Documentation and C1 admission reveal that laundry services are being met. Staff interviews, documentation obtained and C1 admission reveal the medication distribution are being met, per Physician's order. C1 states refusal of medication as a personal right. Documentation obtained and C1 admission, reveal that staff is entering C1's room to perform cleaning and laundry service when C1 is not at the facility and knock and ask for permission to enter while C1 is at the facility to perform those duties.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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-20220913092933

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: 02/15/2023

NARRATIVE

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Based on the information obtained there is not enough evidence that staff are not ensuring that resident's showering needs are being met, staff are not ensuring that resident's laundry needs are being met, staff are not ensuring that resident is taking their medication(s) as prescribed by their physician, staff are not according privacy to resident. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

LIC9099 (FAS) - (06/04)

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