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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530032
Report Date: 10/29/2025
Date Signed: 10/29/2025 04:50:48 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
12/23/2022 and conducted by Evaluator Javier Prieto
COMPLAINT CONTROL NUMBER: 56-AS-20221223094924
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: 132DATE:
10/29/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Marc Pacia, Executive DirectorTIME COMPLETED:
04:55 PM
ALLEGATION(S):
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Questionable death.

Staff are not sanitizing common area bathrooms.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto conducted a visit to the facility to deliver the findings of a complaint investigation into the allegation mentioned. Upon arrival, LPA Prieto identified himself and explained the purpose of the visit to Executive Director Pacia .

Allegation: Questionable Death. The Department’s investigation included interviews with facility staff and residents, LPA collected and reviewed relevant facility records, and review of residents #1 (R1’s) medical and death records. According to documentation obtained R1 passed away on December 21, 2022. The death certificate and supporting medical records indicate that R1’s cause of death was due to natural causes, complications from underlying medical conditions. Based on the interviews conducted and documents reviewed, including medical documentation, the Department did not find sufficient or corroborating evidence to support the claim that R1’s death was questionable or that the facility failed to provide appropriate care and supervision.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
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-20221223094924
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: 10/29/2025
NARRATIVE
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Allegation: Staff are not sanitizing common area bathroom. LPA Prieto toured facility with Executive Director Pacia and observed that common bathrooms and were found to be clean and sanitized. LPA interviewed resident #1 (R1), R2, R3, R4, R5, R6 and R7, all stating that the bathrooms in the common area are clean and sanitized.

The allegation of a questionable death is unsubstantiated. This means that although the allegation may have occurred or is valid, there is not enough evidence to prove that the facility was negligent in the care or supervision of R1.

An exit interview was conducted, and a copy of this report (LIC9099) was provided to Administrator Pacia.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2