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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361800442
Report Date: 01/16/2024
Date Signed: 01/16/2024 04:13:45 PM

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
06/26/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200626143915
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: 6DATE:
01/16/2024
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Douglas Baker, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff are not trained sufficiently.
Facility failed to report incidents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation(s) noted above. LPA met with Douglas Baker, Administrator and explained the purpose of the visit and elements of the allegation(s). The allegations were investigated, the investigation consisted of observations, interviews and records review.

On 06/26/20, Community Care Licensing received a complaint alleging that staff are not trained sufficiently. It was reported that staff did not know how to lift a bedridden resident. In regards to the allegation, the information reported could not be corroborated. Per interviews conducted with facility staff they received training and that Resident #1(R1) would become aggressive and not want care to continue. Staff could not recall if R1 was a two person assist. Additionally, staff reported the training received consists of online, reading materials/booklets and then tests. In addition, LPA reviewed 5 facility files and observed for there to be training checklist, showing proof of ongoing 20 hours of training received
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
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 8
Control Number 18-AS-20200626143915
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: 01/16/2024
NARRATIVE
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annually. However, LPA observed that no staff files had a current CPR/First aid training certification. Based on records review the allegation of staff are not trained sufficiently is SUBSTANTIATED.

Facility failed to report incidents.

It was alleged that Resident #1 (R1) had their ring and watch stolen from Staff # 1 (S1). In addition, some facility camera equipment was also observed to have been stolen. Per interviews conducted with the Licensee, Roger Baker and Administrator, Douglas Baker, R1s responsible party reported that their ring and watch was stolen. However, the items were not locked up for safe keeping by staff. Licensee and Administrator stated that a police report was filed with Rancho Cucamonga Sheriff’s department. Per Licensee and Administrator, the items were unable to be retrieved, but the camera equipment was located at in different county. LPA conducted a review of the facility files and the incident was not reported to the department.

Based on interviews and facility file reviews, the allegations are SUBSTANTIATED. A finding that the complaint allegations are substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Facility is cited in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8), which poses a potential health, safety and/or personal rights risk to persons in care.

An exit interview was conducted and a copy of this report, LIC 9099-D, and appeal rights were provided to Administrator Douglas Baker.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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
06/26/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200626143915

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: 6DATE:
01/16/2024
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Douglas Baker, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not seek emergency medical care in timely manner.
Staff stole items from resident.
There are not enough competent staff on duty to care for residents' needs.
Facility is not screening staff prior to hiring.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation(s) noted above. LPA met with Administrator, Douglas Baker, and explained the purpose of the visit and elements of the allegation(s). The investigation consisted of observations, interviews and records review.

On 06/26/20, Community Care Licensing received a complaint alleging that staff did not seek emergency medical care in a timely manner, it was alleged that on or around May 2020, Resident #1 (R1) became unresponsive while sitting at the table. It was reported that the staff on duty did not lift R1, nor call emergency medical services until three (3) hours later. It was alleged that R1 had a stroke. Per interviews conducted with facility staff, they do not recall R1 having a stroke or exhibiting any symptoms of a stroke. Interviews further revealed that R1 would often fall asleep while sitting at the table. Staff did recall R1 having a fall inside their bedroom, resulting in a small bruise on their elbow. Additionally, R1s responsible party was contacted and decided not to send R1 out after a visual assessment check was completed.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 18-AS-20200626143915
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: 01/16/2024
NARRATIVE
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Therefore the allegation of staff did not seek emergency medical care in a time manner is UNSUBSTANTIATED.

There are not enough competent staff on duty to care for residents' needs.

It was reported that there are not enough competent staff on duty to care for residents’ needs. Per interviews conducted with the Administrator Douglas there was a brief time for the month in September 2020, where the facility was having a challenging time with facility staff not getting along. There were some staff that expressed that they no longer wanted to work at the facility if there were certain staff still there. Due to the issues with staff, certain staff received additional hours to ensure residents were properly cared for and supervised. Further information from staff interviews, Resident #1 (R1) was described as being aggressive at times and would refuse care. R1 is unable to be interviewed as they are deceased. The facility is licensed for six (6) residents and currently has a census of six (6) residents. The facility currently has a total of 14 staff on the roster. During the AM and PM shift there are 2 caregivers on in addition to the Administrator being present on grounds. During the Noc shift there is a wake caregiver as well as the administrator that lives on the premises. Due to insufficient evidence to corroborate the allegation of there are not enough competent staff on duty to care for residents’ needs is UNSUBSTANTIATED.

Facility is not screening staff prior to hiring.

It was reported that the facility is not screening staff prior to hiring. LPA conducted a review of six (6) staff files and observed for the staff files to have a Caregiver employee verification checklist completed. All staff currently working at the facility have obtained criminal record clearance and are associated to the facility. Per an interview with Administrator Douglas, posting the job using an online hiring search engine, the screening process includes reviewing the applicants background, an interview which includes asking what their desires are, referral review, and if the applicant has reliable transportation. Administrator Douglas stated that he is the one that is responsible for hiring staff and that all staff are screened in person. Based on a records review and interviews the allegation is UNSUBSTANTIATED.

Staff stole items from resident.

It was alleged that Resident #1 (R1) had their ring and watch stolen from Staff # 1 (S1). In addition, some facility camera equipment was also observed to have been stolen. Per interviews conducted with the Licensee

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 18-AS-20200626143915
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: 01/16/2024
NARRATIVE
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Roger Baker and Administrator Douglas Baker, R1 did in fact have their ring and watch stolen. However, the items were not locked up for safe keeping by staff but was on R1s person. The licensee and Administrator stated that a police report was filed with Rancho Cucamonga Sheriff’s department. Per licensee and Administrator Baker, the watch and ring were unable to be retrieved, but the camera equipment was located at a pawn shop in a different county, as there were serial numbers on the equipment. Additional feedback from interview with Administrator S1 was “arrested and put back into prison”.

Based on interviews, record review, and observation, the allegations listed above are UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s) occurred. Based on interviews the allegation is UNSUBSTANTIATED.

An exit interview was conducted and a copy of this report was provided to Douglas Baker, Administrator.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 18-AS-20200626143915
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: 01/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/17/2024
Section Cited
HSC
1569.618(c)(3)
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1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at
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staff not having CPR certification. The Licensee agrees to enroll all staff to . Proof of plan of correction is to be submitted to the department by 5pm on the due date indicated.
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least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidence by 6
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The Licensee agrees to enroll staff in CPR/First Aid, training. Proof is to be submitted to the department by 5pm on the due date indicated.
Type B
01/31/2024
Section Cited
CCR
87211(a)(1)
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Reporting requirements87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including...the following: (1) A written report shall be submitted to the licensing agency...within 7 days of the occurrence of any of the events...
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Licensee agreed to conduct staff training on reporting requirements. The training material and sign-in sheet will be provided to the Department as proof of POC by the due date.
Type B
CCR
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This requirement was not met, as evidenced by: Based on interviews and record review, the Licensee did not ensure the theft was reported to the Department within 7 days of the occurrence.This poses a potential risk to the health, safety or personal rights of the 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.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
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
06/26/2020 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200626143915

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: 6DATE:
01/16/2024
UNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Douglas Baker, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility failed to safeguard resident's property.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation(s) noted above. LPA met with Administrator, Douglas Baker, and explained the purpose of the visit and elements of the allegation(s). The investigation consisted of observations, interviews and records review.

On 06/26/20, Community Care Licensing received a complaint alleging that Resident #1 (R1) had their watch and ring stolen from facility staff. In addition, some facility camera equipment was also observed to have been stolen. Per interviews conducted with the Licensee, Roger Baker and Administrator, Douglas Baker, R1 did in fact have their ring and watch stolen. However, the items were not locked up for safe keeping by staff, but was on R1s person. Licensee and Administrator stated that a police report was filed with Rancho Cucamonga Sheriff’s department. Per Licensee and Administrator, the items were unable to be retrieved. Additional feedback from interview with Administrator S1 was “arrested and put back into
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 18-AS-20200626143915
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: 01/16/2024
NARRATIVE
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prison”. Further, per Administrator, residents and their responsible parties are encouraged to not to bring anything that they define as valuable. The following statements are documented or verbally expressed ”Per the facility’s theft and loss program the facility does not accept residents cash or belongings that are valuable”. “Personal property inventory shall be completed by the responsible party of the resident”. LPA attempted to conduct resident interviews and LPA was unable to successfully obtain information.
Based on interviews and records review the allegation of facility failed to safeguard resident’s property is UNFOUNDED.


An exit interview was conducted and a copy of this report was provided to Douglas Baker, Administrator.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8