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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336403573
Report Date: 12/05/2025
Date Signed: 12/05/2025 02:27:25 PM

Substantiated


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
01/29/2025 and conducted by Evaluator Armando Perez
COMPLAINT CONTROL NUMBER: 18-AS-20250129091300
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: 32DATE:
12/05/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director Danai VergaraTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Facility staff handle resident in a rough manner
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA), Armando Perez and Robert Cambpell, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegations. LPA Perez met with Executive Director Danai Vergara, where the LPA explained the purpose of the visit and the elements of the allegation. The investigation consisted of interviews with staff and witnesses and file reviews.

On January 29, 2025, Community Care Licensing Division (CCLD) received a complaint alleging that facility staff handled resident in a rough manner. It was alleged that staff members forcibly restrained a resident in care, disregarding the resident’s expressed objections. It was reported that Resident #1 (R1) was inappropriately restrained by staff.
During an interview, Health Facility Evaluator Nurse, Tamera Wiles (AW1), an employee of California Department of Public Health reported that on January 28, 2025, she observed multiple staff members aggressively restraining R1 in a chair during an attempted elopement.
Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20250129091300
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: 12/05/2025
NARRATIVE
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AW1 noted that R1 verbally instructed staff to stop and subsequently began yelling for help. AW1 intervened to de-escalate the situation.

Interview with Director of Assisted Living, Michelle Flores (DAL), corroborated statements provided by AW1. Additionally, DAL reported that an internal investigation was conducted and appropriate steps were taken, such as termination of involved staff and staff training on Dementia Behavior and Resident Personal Rights. Interview with Responsible Party (RP) confirmed they were made aware of the incident involving R1. RP emphasized the issue with staff was isolated and there were no further concerns. LPA attempted to interview R1 and R1 refused to be interviewed.

LPA documented a review of the surveillance video, confirming that the footage corroborated the alleged events. LPA noted the video lacked audio; however, the footage was adequate to establish the sequence of events.

Based on interviews, record reviews, and observation, the allegation that staff handled resident in a rough manner is Substantiated. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met, which poses a risk to the health and safety of the clients in care. The facility will be cited.

An exit interview was conducted. A copy of this report was provided to Executive Director Danai Vergara, along with a copy of the LIC9099-C, LIC9099D, and Appeal Rights.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20250129091300
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2025
Section Cited
CCR
87468.1(a)(3)
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87468.1Personal Rights of Residents in All Facilities(a) Residents…shall have all of the following personal rights(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as…interfering with daily living functions.
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Administrator will provide in-service training to staff regarding Dementia Behavior and Resident Personal Rights and email a copy to LPA
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This requirement was not met as evidenced by:Through interviews observations and records review staff
did not respond in a proper manner resulting in a personal rights violation which is a potential health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Armando Perez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2025
LIC9099 (FAS) - (06/04)
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