336403573-8-28-2023-18-AS-JDHS-CV9SEP-20230901134900

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336403573
Report Date: 08/28/2023
Date Signed: 08/28/2023 02:23:56 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
02/25/2022 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220225145157

FACILITY NAME:	VILLAGE, THE		FACILITY NUMBER:	336403573
ADMINISTRATOR:	ROB TAKAMI		FACILITY TYPE:	741
ADDRESS:	2200 WEST ACACIA		TELEPHONE:	(951) 766-5116
CITY:	HEMET	STATE: CA	ZIP CODE:	92545
CAPACITY:	452	CENSUS: 350	DATE:	08/28/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Danai Vergara, Executive Director		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Resident was inappropriately touched while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to deliver findings to an investigation regarding the above allegation. LPA met with Executive Director Danai Vergara who was informed of the purpose of the visit. LPA then conducted a tour of the facility.

It was alleged that Resident #1 (R1) was sexually assaulted by someone touching R1’s knees. There was no description of the person involved, and it was unknown if they were staff, or another resident. The allegation further stated that R1 did not have fresh bruising on their knees.

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: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

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-20220225145157

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: VILLAGE, THE	FACILITY NUMBER: 336403573
	VISIT DATE: 08/28/2023

NARRATIVE

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The Department’s investigation consisted of record review, interview of staff, and interview of R1’s Power of Attorney (POA). LPA found that R1 was not able to be interviewed due to passing away in September 2022. Record review indicated that R1’s behaviors escalated during the month of 2/2022. A facility progress note dated 2/22/22, indicated that R1’s delusions were centered around R1’s belief that the staff were poisoning residents and R1. Resident also had flashbacks of a sexual assault that R1 suffered in R1’s past. R1 had psychosis with symptoms that included bizarre behavior, thought disorder, illogical reasoning, paranoid delusions, and paranoid manner. Interview with POA indicated that POA visited R1 daily, and never witnessed any misconduct to R1 by staff or other residents. Additionally, POA mentioned that R1 had a diagnosis that made R1 extremely paranoid and would often imagine unrealistic events. Staff interviews corroborated POA’s statement in R1’s behavior. Due to the time lapse, no other information could be revealed in this case; therefore, at this time, this allegation was Unsubstantiated.

The Department could not dismiss the complaint. 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 along with a copy of the LIC811 (confidential names list).

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 08/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023

LIC9099 (FAS) - (06/04)

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