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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336403573
Report Date: 03/03/2022
Date Signed: 03/03/2022 10:35:39 AM

Unfounded


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
02/25/2022 and conducted by Evaluator David Cuevas
COMPLAINT CONTROL NUMBER: 18-AS-20220225145157
FACILITY NAME:VILLAGE, THEFACILITY NUMBER:
336403573
ADMINISTRATOR:ROB TAKAMIFACILITY TYPE:
741
ADDRESS:2200 WEST ACACIATELEPHONE:
(951) 766-5116
CITY:HEMETSTATE: CAZIP CODE:
92545
CAPACITY:452CENSUS: 62DATE:
03/03/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Assistant Director, Michelle F. TIME COMPLETED:
10:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was inappropriately touched while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 3/3/2022 Licensing Program Analyst (LPA), David Cuevas conducted an announced visit to the facility to investigate the allegation above. LPA identified himself and was granted entry. LPA met with Assistant Director, Michele F. who was informed of the purpose of the visit.

Upon meeting with Michele F. LPA was asked if the complaint was for the assisted living or skilled nursing site. LPA provided the allegation and name of the resident and was informed that resident # 1 (R1) identified in the allegation, does not reside in this facility, but was a patient at the skill nursing site, which is not licensed by CCL. LPA was presented with a roster from the skilled nursing site that identifies R1 to be a patient in skilled nursing. Additionally, during today’s visit, LPA was informed that R1, has been sent out to a hospital, and is not available for an interview.

Based on the collected information and documents provided, the allegation of, Resident was inappropriately touched while in care is found to be UNFOUNDED., meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

An exit interview was conducted and a copy of this report was provided to Michele F.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: David CuevasTELEPHONE: (951) 295-3927
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
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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