336401178-5-6-2022-18-AS-JESL-CHNTDB-20220826143804

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336401178
Report Date: 05/06/2022
Date Signed: 05/06/2022 01:36:50 PM

Substantiated

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
05/03/2022 and conducted by Evaluator Crystal Colvin

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220503120310

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: 5	DATE:	05/06/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Teodora San Juan - Licensee/Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident sustained bruising by staff while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified herself and discussed the purpose of the visit and the elements of the allegation(s) with Licensee/Administrator Teodora San Juan. Below is a summary of the complaint investigation findings:

Regarding allegation "Resident sustained bruising by staff while in care": LPA Colvin reviewed resident (R1) file, interviewed staff and residents, and observed bruising to R1's right arm. Through interviews, it was agreed that R1 sustained the bruise during an incident in the facility's kitchen where R1 was holding a mallet and staff member (S1) attempted to get the mallet out of R1's hand. The facility does not have any documentation of the event, and R1 was not taken to the hospital (for this incident). Interviews with the Administrator confirmed that S1 grabbed R1's arm, which resulted in the large bruise on R1's right arm. Therefore, due to observations and interviews, the allegation "Resident sustained bruising by staff while in care" is SUBSTANTIATED.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

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-20220503120310

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: 05/06/2022

NARRATIVE

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A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited, and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to Administrator Theodora San Juan during the exit interview.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

LIC9099 (FAS) - (06/04)

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Citations on this Visit Report are Under Appeal!

Control Number 18-AS-20220503120310

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/06/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type A 05/09/2022 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Personal Rights...in All Facilities: (a) In addition to the rights listed...residents...shall have...the following personal rights:(4) To care, supervision...that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency...This requirement was not met by:	1 2 3 4 5 6 7	Licensee agrees to retrain staff on proper de-escalation measures and techniques to protect themselves and others without causing harm to the residents. Licensee to provide LPA Colvin with proof of training by Plan of Correction date of 5/9/22.
	8 9 10 11 12 13 14	Based on observations and interviews, the Licensee did not comply with the above regulation with one resident. LPA Colvin confirmed that R1 sustained bruising on their right arm from S1 grabbing them. S1 failed to implement other measures to ensure safety. This was an immediate personal rights violation	8 9 10 11 12 13 14
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Crystal Colvin	TELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:	DATE: 05/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022

LIC9099 (FAS) - (06/04)

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