336402944-10-5-2023-18-AS-RSTS-CXYT4T-20231127132427

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336402944
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:13:29 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
01/21/2022 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220121125403

FACILITY NAME:	VILLA SAN JUAN BOARD & CARE FOR THE ELDERLY #2		FACILITY NUMBER:	336402944
ADMINISTRATOR:	TEODORA L. SAN JUAN		FACILITY TYPE:	740
ADDRESS:	786 DE PASSE WAY		TELEPHONE:	(951) 765-9202
CITY:	HEMET	STATE: CA	ZIP CODE:	92544
CAPACITY:	6	CENSUS: 6	DATE:	10/05/2023
		UNANNOUNCED	TIME BEGAN:	02:17 PM
MET WITH:	Teodora San Juan, Administrator		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Licensee does not follow COVID-19 protocol

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to the facility to deliver findings to the above allegation. LPA met with Administrator Teodora San Juan who was informed of the purpose of visit and granted entry. LPA then conducted a tour of the facility.

Regarding the allegation, it was alleged that the Licensee was not allowing residents to have the booster COVID-19 vaccine. Through interviews with staff, and other relevant sources, LPA found that there was not enough evidence to corroborate the allegation made. Interviews with residents were attempted, but credible information was not able to be obtained due to their cognitive level.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

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 18-AS-20220121125403

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VILLA SAN JUAN BOARD & CARE FOR THE ELDERLY #2	FACILITY NUMBER: 336402944
	VISIT DATE: 10/05/2023

NARRATIVE

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Through interview, staff indicated that they did not interfere with residents obtaining the booster vaccine. Staff relayed they, themselves have the booster vaccine, and if a booster was decided either by themselves, or their responsible party, they were allowed to have it. Additionally, interview(s) with relevant source(s) indicated that the facility was very active in providing resources to residents to obtain the booster. Based on interviews and evidence obtained, the Department found that this allegation was Unsubstantiated.

A finding of UNSUBSTANTIATED means that 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.

An exit interview was conducted where a copy of this report was discussed with and provided.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023

LIC9099 (FAS) - (06/04)

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