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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603861
Report Date: 04/26/2025
Date Signed: 04/26/2025 01:53:41 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
02/06/2023 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 18-AS-20230206110201
FACILITY NAME:KELLY'S VISTA VILLAFACILITY NUMBER:
374603861
ADMINISTRATOR:GARDNER, BABETTEFACILITY TYPE:
740
ADDRESS:1691 LONE OAK ROADTELEPHONE:
(760) 295-7102
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 3DATE:
04/26/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:ADMINISTRATOR KELLY WELKERTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not address a resident's hygiene needs while in care
INVESTIGATION FINDINGS:
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On 04/26/2025 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Kelly’s Vista Villa and was greeted by Staff Daniel Carballo (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the finding pertaining to the above-mentioned allegation.

The investigation consisted of the following: LPA Calderon interviewed Staff S1, resident R1-R3. LPA Calderon obtained the following records: Admission agreement (dated 07/13/2022), physician report (dated 08/14/2022), grooming logs notes (brushing resident teeth) (dated 02/2023 to 04/2025), for R1.

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2025
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 2
Control Number 18-AS-20230206110201
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: KELLY'S VISTA VILLA
FACILITY NUMBER: 374603861
VISIT DATE: 04/26/2025
NARRATIVE
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Regarding the Allegation: Staff did not address a residents hygiene needs while in care.

This complaint alleged that the facility staff did not brush R1 teeth weekly. Records review indicate the following: Physician report indicate R1 is verbal and has health issues. Admission agreement indicates that resident moved into the facility on 07/13/2022. Admission agreement page 7 section 10 and 16 indicate that staff will help with R1 hygiene and dental needs. Agreement does not indicate how many times per week the R1 teeth will be brushed. Teeth brushing Calander indicates that staff has brushed R1 teeth 7 days a week from 02/2023 to 04/2025.Interviews indicate the following: S1 indicates that staff brush R1 teeth 7 days a week and a calendar is kept for their records. S1 indicates that they help R1 brush R1 teeth 7 days a week and keep a calendar of which staff brush R1 teeth and how often. R1-2 could not answer any questions due to health issues and was non-verbal. R3 indicates that R3 brushes R3 teeth every day with no help from staff.

Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff did not address a residents hygiene needs while in care” is found to be UNSUBSTANTIATED.

No deficiencies cited during today's visit.



An exit interview was conducted, and a copy of the Complaint Report were provided to the Staff Daniel Carballo (S1).
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2