336401178-9-29-2021-18-AS-EMAN-CBGQH4-20220209111033

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336401178
Report Date: 09/29/2021
Date Signed: 09/29/2021 10:51:02 AM

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
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/13/2021 and conducted by Evaluator Stephanie Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210713121407

FACILITY NAME:	VILLA SAN JUAN BOARD & CARE FOR ELDERLY		FACILITY NUMBER:	336401178
ADMINISTRATOR:	SAN JUAN, TEODORA L.		FACILITY TYPE:	740
ADDRESS:	798 DE PASSE WAY		TELEPHONE:	(951) 765-9202
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	6	CENSUS: 6	DATE:	09/29/2021
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Teodora San Juan		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Resident being chemically restrained
Resident sustained an injury while in care.
Facility not allowing resident to have visitors.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Stephanie Williams conducted an unannounced visit to the facility in order to deliver findings for the above allegations. LPA Williams identified herself and met with Administrator, Teodora San Juan. The investigation consisted of records review and interviews with staff, residents, and witnesses.

In regards to allegation #1, LPA Williams interviewed Resident #1 (R1) who denied that facility staff is crushing resident’s medications. LPA found no indications that R1 required crushed medications as ordered by physician in R1’s records. LPA Williams reviewed R1’s records, which indicated that R1 has a history of accusatory and paranoid behaviors. LPA interviewed Staff #1 (S1) who denied that the residents are being chemically restrained by providing them with crushed sleeping pills. LPA interviewed Staff #2 (S2) and Staff # (S3), who both also denied providing residents with crushed sleeping pills. LPA interviewed Resident #2 (R2) who stated that they do not believe the facility staff is providing residents with crushed sleeping pills. R2 stated that the other residents are lower functioning; however, they are usually alert. At the time of visit,

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

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 18-AS-20210713121407

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
RIVERSIDE, CA 92507

FACILITY NAME: VILLA SAN JUAN BOARD & CARE FOR ELDERLY	FACILITY NUMBER: 336401178
	VISIT DATE: 09/29/2021

NARRATIVE

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LPA observed that all residents appeared to be alert and out of bed.

In regards to allegation #3, LPA Williams interviewed Resident #1 (R1) who denied experiencing a fall and injuring their foot. R1 did state that they once experienced a fall and hurt their back. When LPA asked R1 how and when they fell, R1 stated, “I don’t know but I know I fell because I am weaker.” R1 could not provide any further details. LPA interviewed S1 who could not recall an incidence where R1 experienced a fall. S1 stated that R1 did not report any falls to S1. LPA interviewed S2 and S3 who denied having any knowledge of R1 experiencing a fall. LPA interviewed R2 who denied witnessing R1 fall in the common areas. LPA reviewed the Regional Office’s (RO’s) incident report log, which did not show that an incident report was sent to the RO regarding R1’s alleged fall.

In regards to allegation #3, LPA Williams interviewed R1 who stated that S1 is not allowing R1’s pastor to visit. S1 denied the allegation, stating that R1’s pastor has come to the facility on many occasions. S1 stated that all residents may have visitors as long as the facility visitation rules, and COVID-19 guidelines are being followed. LPA interviewed R2, who stated that they have seen residents with their visitors at the facility. R2 denied that facility staff are not allowing residents to have visitors. LPA was unable to locate R1’s pastor to retrieve statement.

Based on evidence obtained during the investigation, LPA has determined that the above allegations are UNSUBSTANTIATED; meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report was discussed and a copy was provided to the Administrator.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Stephanie Williams	TELEPHONE: (951) 248-0317
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC9099 (FAS) - (06/04)

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