<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800442
Report Date: 09/14/2023
Date Signed: 09/14/2023 10:32:04 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2020 and conducted by Evaluator Chinwe Nwogene
COMPLAINT CONTROL NUMBER: 18-AS-20200207104749
FACILITY NAME:VILLA LIVINGFACILITY NUMBER:
361800442
ADMINISTRATOR:BAKER, DOUGLASFACILITY TYPE:
740
ADDRESS:9377 VALLEY VIEW STREETTELEPHONE:
(909) 727-3663
CITY:RANCH CUCAMONGASTATE: CAZIP CODE:
91737
CAPACITY:6CENSUS: 5DATE:
09/14/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Douglas Bake, AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Residents needs not being meet.
Residents not being provided their medications as prescribed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/14/2023, Licensing Program Analyst (LPA), Chinwe Nwogene conducted an unannounced visit to conclude the complaint investigation into the allegations listed above. During the visit, LPA met with Administrator, Douglas Baker. During the investigation staff and resident file was reviewed.

Regarding the allegation “Residents needs not being meet” it was alleged staff are not properly administering resident’s medications. Staff were interviewed who denied not properly administering resident’s medications. Staff stated staff follows doctor’s order when administering resident’s medication. Resident’s November 2019, December 2019, and January 2020 Medication Administration Records (MAR) were reviewed and revealed several days were four #4 medications Dorzolamide Timolol eye drops, Travan Eye drops, Oasis Tear Plus Lubricant, eye drops, Oasis Lid wipes were not administered or logged. Substantiated.

Regarding the allegation “Residents not being provided their medications as prescribed” it was alleged that staff isn’t administering resident’s eye medication. Staff was interviewed who stated staff administered resident’s medication according to doctor’s orders. Resident’s November 2019, December 2019, and January 2020 Medication Administration Records (MAR) were reviewed.

Continue on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
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-20200207104749
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: VILLA LIVING
FACILITY NUMBER: 361800442
VISIT DATE: 09/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continued from LIC9099

MAR revealed,

Dorzolamide Timolol eye drops to be given two times a Day at 8 AM and 4PM: 11/2019 AM shows one day missed, and PM shows four days missed. 12/2019 AM shows four days missed and PM zero days missed. 01/2020 AM shows zero days missed and PM three days missed.

Travan Eye drops, one drop a day at bedtime: 11/2019 shows five days missed, 12/2019 shows three days missed. 01/2020 shows ten days missed.

Oasis Lid wipes, once a day: 11/2019 shows nine days missed. 12/2019 shows twenty-one days missed. 01/2020 shows twenty-four days missed.

Oasis Tear Plus Lubricant, eye drops to be used daily: 11/2019 shows all month no entry for a total of 30 days. 12/2019 shows all month no entry for a for a total of 31 days. 01/2020 shows all month no entry for a for a total of 31 days. Substantiated.

Based on observations, interviews conducted and a resident record review, the preponderance of evidence standard has been met. Therefore, the above allegations are found to be substantiated. California Code of Regulations (Title 22, Division & Chapter number 6) are being cited on the attached LIC 9099D). An exit interview was conducted, and a copy of this report was reviewed with and provided along with appeals right to Douglas Baker.

SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20200207104749
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: VILLA LIVING
FACILITY NUMBER: 361800442
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
09/22/2023
Section Cited
CCR
87464(f)(4)
1
2
3
4
5
6
7
87464 Basic Services;
(f) Basic services shall at a minimum include:
(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications.
1
2
3
4
5
6
7
Administrator stated caregivers has been trained on medication administration and a proof of training will be provided to LPA by the due date 9/22/2023.
8
9
10
11
12
13
14
This requirement is not met based as evidence by interview, and record review. The licensee did not comply by not properly administering resident’s medications as prescribed which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Request Denied
Type B
09/22/2023
Section Cited
CCR
87464(f)(4)
1
2
3
4
5
6
7
87464 Basic Services;
(f) Basic services shall at a minimum include:
(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications.
1
2
3
4
5
6
7
Administrator stated caregivers has been trained on medication administration and a proof of training will be provided to LPA by the due date 9/22/2023.
8
9
10
11
12
13
14
This requirement is not met based as evidence by interview, and record review. The licensee did not comply by not administering resident’s eye medication as prescribed which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: Deborah MullenTELEPHONE: (951) 248-8031
LICENSING EVALUATOR NAME: Chinwe NwogeneTELEPHONE: (951) 202-2066
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3