374603861-5-19-2025-18-AS-RORN-DGUPK7-20250520112238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603861
Report Date: 05/08/2025
Date Signed: 05/19/2025 08:15:44 AM

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 VILLA		FACILITY NUMBER:	374603861
ADMINISTRATOR:	GARDNER, BABETTE		FACILITY TYPE:	740
ADDRESS:	1691 LONE OAK ROAD		TELEPHONE:	(760) 295-7102
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	6	CENSUS: 3	DATE:	05/08/2025
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Licensee Kelly Welker		TIME COMPLETED:	02:15 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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05/08/2025 Licensing Program Analyst (LPA) Jose Calderon provided an updated complaint investigation report to the licensee/administrator Kelly Welker via telephone. The purpose of the meeting is to clarify and provide additional information not included on the previous report dated 04/26/2025.

The investigation consisted of the following:

On 04/26/2025, 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 02/06/2023 to 04/26/2025), for R1. On 05/07/2025 LPA Calderon interviewed administrator, staff S2-S4 and attempted to interview witness W1-W2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

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-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: 05/08/2025

NARRATIVE

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The investigation revealed the following:

Regarding the Allegation: Staff did not address a residents hygiene needs while in care. It is being alleged that the facility staff did not brush a resident’s teeth daily. Record reviews indicate the following: Physician report indicate that R1 is verbal and requires assistance with hygiene needs. Admission agreement indicates that R1 moved into the facility on 07/13/2022. Page 7 section 10 and 16 of the admission agreement indicates that staff will help R1 with hygiene and dental needs. The agreement does not indicate how many times per week R1’s teeth will be brushed. The facilities teeth brushing Calendar indicates that staff has brushed R1’s teeth 7 days a week from 02/06/2023 to 04/26/2025. Interviews indicate the following: Staff S1-S4 denied the allegation that R1’s hygiene needs which includes brushing of R1’s teeth daily are not addressed by staff. S1-S4 also indicates that hygiene records are kept for R1’s teeth brushing. Residents R1-R2 could not answer any questions due to health issues and were non-verbal. R3 indicates that R3 brushes their own teeth every day with no help from staff. LPA Calderon attempted to interview residents responsible persons witness W1-W2 multiple times but there were no responses.

Based on interviews and supporting documentation, the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred therefore, the allegation of “staff did not address a residents hygiene needs while in care” is found to be Unsubstantiated.

No deficiencies cited. An exit interview was conducted, and a copy of this Complaint Report was provided via email to the Licensee/Administrator Kelly Welker for signature.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025

LIC9099 (FAS) - (06/04)

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