374604820-4-21-2026-08-AS-BCHN-DTDUQN-20260422154724

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604820
Report Date: 04/21/2026
Date Signed: 04/21/2026 12:21:36 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/20/2025 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 08-AS-20250220113308

FACILITY NAME:	NEW WORLD VILLA SOUTH		FACILITY NUMBER:	374604820
ADMINISTRATOR:	CHEN, ZAYDEN		FACILITY TYPE:	740
ADDRESS:	14125 TARZANA RD		TELEPHONE:	(858) 748-2888
CITY:	POWAY	STATE: CA	ZIP CODE:	92064
CAPACITY:	6	CENSUS:	DATE:	04/21/2026
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Zayden Chen		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident sustained an injury due to lack of supervision

INVESTIGATION FINDINGS:

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On 4/21/2026, LPA Grace Donato conducted a telephone interview with the facility to deliver findings. LPA spoke with Zayden Chen and explained the purpose of the call.

For the allegation of resident sustained an injury due to lack of supervision, reporting party (RP) stated that a resident (R1), had fallen down on the floor in two consecutive days. On the second incident, R1 sustained head injury and was sent to hospital.

On 10/22/2024, R1 had a mechanical fall injury. R1 accidentally tripped and fell while using the bathroom sustaining a one-inch laceration on the head. Facility staff (S1) called 911, paramedics arrived and R1 was sent to hospital. An unusual incident/injury report was made to Community Care Licensing (CCL).

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026

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 08-AS-20250220113308

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: NEW WORLD VILLA SOUTH	FACILITY NUMBER: 374604820
	VISIT DATE: 04/21/2026

NARRATIVE

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R1s family member (F1) stated that F1 took R1 to hospital on 10/21/2024, for an evaluation of shortness of breath. R1 had no respiratory distress and was not admitted as there was no evidence or respiratory distress at that time, therefore there was no unusual incident/injury report made to CCL.

Based on the corroborating evidence and statements made by staff and family there is no evidence to show neglect/lack of care of supervision resulting in serious bodily injury or delayed medical care of R1.

Based on interviews, observations and records review, the department has determined that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Report is reviewed and copy is provided.

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SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2026

LIC9099 (FAS) - (06/04)

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