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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530032
Report Date: 05/26/2023
Date Signed: 07/28/2025 01:21:17 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
04/04/2023 and conducted by Evaluator Javier Prieto
COMPLAINT CONTROL NUMBER: 56-AS-20230404134825
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: 106DATE:
05/26/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Patrick McAdoo Morton, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
1
2
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9
Resident is being neglected while in care
Staff leave resident unattended in dirty diapers for extended periods
Staff failed to provide adequate food service
Staff failed to assist resident in care
INVESTIGATION FINDINGS:
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2
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5
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13
Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the listed allegations. LPA Prieto met with Executive Director Morton and explained the elements of the complaint.

Allegation #1 - Resident #1 (R1), in question, states the staff attend to his needs. R1 adds his call button is pressed for services pertaining to bathing and cleaning. Staff #1 (S1) states R1 calls staff regarding relating to care services.

Allegation #2 - R1 states staff arrive, once call button is pressed, in matters pertaining to addressing is incontinance needs in a timely manner. Staff interview reveal R1 does utilize the services of staff in relation to incontinance and bathroom transfer needs.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
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-20230404134825
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: 05/26/2023
NARRATIVE
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Allegation #3 - R1 interview reveals staff assist with him with escorting to the dinning area for each meal times. R1 also reveals that has tray service is utilized where staff deliver meals upon R1's request. S1 concluded R1's tray service and escorting to and from to the dinning area during meal times.

Allegation #4 - Staff failed to assist resident in care pertains to call buttons not being answered. R1 interview reveals that the call button is utilized for service from staff related to incontinence care, transfers, escorting and food services. During time of investigation, call button was tested and found to be in working order.

Based on the information obtained there is not enough evidence to support the allegations in this complaint. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Marc Pacia.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2