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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397002540
Report Date: 02/20/2025
Date Signed: 02/20/2025 03:49:59 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/23/2024 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20241223172423
FACILITY NAME:VILLA TERESA 1 CARE HOMEFACILITY NUMBER:
397002540
ADMINISTRATOR:JUSTIN JOSEFACILITY TYPE:
740
ADDRESS:2477 CARPENTER ROADTELEPHONE:
(209) 462-4239
CITY:STOCKTONSTATE: CAZIP CODE:
95205
CAPACITY:6CENSUS: 4DATE:
02/20/2025
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Justin JoseTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident sustained injury while in care due to lack of supervision
INVESTIGATION FINDINGS:
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On 2/20/2025 at 3:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver findings for the allegation noted above. LPA met with Administrator Justin Jose and explained the purpose of the visit. During this investigation, LPA conducted interviews with three staff members and resident1 (R1). LPA also reviewed facility file documentation including individual program plan (IPP), behavior support plan, and physician’s report, and care notes all pertaining to R1. Additionally, LPA reviewed facility’s staffing schedule and conducted facility observations on 12/30/24 and 2/20/2025.

Allegation: Resident sustained injury while in care due to lack of supervision. Based on interviews and record reviews conducted, it was revealed that on 12/22/24 R1 experience a fall and sustained a bruise on right eye. Staffing schedule reviewed for this date and other dates in December 2024 revealed two staff on duty consistently for 6 residents in care. Additionally, it was determined through interviews that resident fell as a result of tripping over clothing items in her room and making contact with bedroom furniture.
{Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
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 27-AS-20241223172423
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VILLA TERESA 1 CARE HOME
FACILITY NUMBER: 397002540
VISIT DATE: 02/20/2025
NARRATIVE
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Care notes reviewed indicate fall was noted and addressed on 12/22/24 by staff. Record reviews and interviews further revealed that R1 has a history of resisting staff assistance with cleaning room and lacks safety awareness. Behavior support plan for R1 indicates interventions are in place to address this behavior. Observations conducted revealed facility staff attending to residents needs adequately.

As a result, although R1 sustained a fall and minor injury while in care, there is not a preponderance of evidence to conclude this was due to a lack of appropriate supervision. Therefore, the above allegation is UNSUBSTANTIATED. A finding of unsubstantiated means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2