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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850354
Report Date: 05/06/2026
Date Signed: 05/06/2026 02:37:12 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2026 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20260501093143
FACILITY NAME:VILLA GARDENSFACILITY NUMBER:
405850354
ADMINISTRATOR:CASTANIAGA, JANELYNFACILITY TYPE:
740
ADDRESS:9385 SANTA CLARA RD.TELEPHONE:
(805) 464-2098
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY:6CENSUS: 4DATE:
05/06/2026
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Janelyn Castaniaga, Licensee/AdministratorTIME COMPLETED:
02:35 PM
ALLEGATION(S):
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Staff are locking residents in rooms
Staff are sleeping while on duty
Staff are not trained to use the hoyer lift
Licensee does not ensure residents have toilet paper in the bathrooms
Licensee does not ensure all toilets are clean
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) De Leon conducted a 10-day complaint visit to the facility above. LPA met with Jane Castaniaga Administrator/Licensee and explained the purpose of the visit.

LPA toured the facility, reviewed records, interviewed administrator at 10:35am, staff around 11:15am and resident at 11:30am.

On the allegation: Staff are locking residents in rooms. Witness statement stated the lock is on the opposite side of the door and it was locked with a person inside. Witness also stated the residents had been locked out on the patio before. LPA interviewed Administrator which revealed the lock on the door was turned around because the resident started to exit seek at night. LPA spoke to the staff which revealed the resident would get out at night so they changed the lock. LPA looked at all bedroom doorknobs and locks which revealed room 5 had a lock on the outside of the door which provides the opportunity for a resident to be locked in, Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026
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 6
Control Number 29-AS-20260501093143
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA GARDENS
FACILITY NUMBER: 405850354
VISIT DATE: 05/06/2026
NARRATIVE
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The current resident in room 5 was in the common area the door was opened and not locked on LPA visit. LPA took a photograph of the lock on the outside of the door. Based on the evidence this allegation is Substantiated at this time.

On the allegation: Staff are sleeping while on duty. LPA interviewed Administrator which revealed a residents family felt the staff was sleeping because she was laying on the couch with the staff eyes closed and she talked with the staff an explained staff can not do so that while working on shift. Staff interviewed stated staff was resting and just had eyes closed but was not sleeping. Witness interview stated the staff was asleep on the couch during the day while residents in care were awake and at the facility. Based on the evidence this allegation is Substantiated at this time.

On the allegation: Staff are not trained to use the hoyer lift. LPA interviewed Administrator which revealed the staff that work at the facility have prior caregiving experience and staff know how to use the Hoyer Lift with resident in care, facility did not train any staff in the hoyer lift and facility does not have any records of training on the hoyer lift. Staff interviewed revealed the staff knows how to use the hoyer lift and worked in caregiving prior and had learned how to use it then. Witness stated the staff was not trained on using the hoyer lift with a resident in care. Due to the facility's lack of training records or documentation this allegation is Substantiated at this time.

On the allegation: Licensee does not ensure residents have toilet paper in the bathrooms. Witness statement revealed the bathrooms do not have toilet paper for residents use. LPA toured the facility, the main bathroom did not have toilet paper, Room 3 bathroom did have toilet paper and room 4 & 5 have a shared bathroom that did have toilet paper. Resident interview said sometimes the bathroom has toilet paper and sometimes it does not, resident said if the resident asks the staff the staff will get the resident toilet paper. Administrator stated they were hiding the toilet paper from 1 resident due to the resident clogging up the toilet and it overflowing all over the bathroom and out into the living area causing a safety issue, the resident has clogged the toilet several times, staff told the resident to ask the staff for toilet paper if the resident needs it and the staff will bring it to the resident. LPA asked the Administrator if the facility had any doctor documentation that the resident can not have access to regular grooming and hygiene items, the Administrator stated no the facility did not. Based on evidence this allegation is Substantiated at this time.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20260501093143
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA GARDENS
FACILITY NUMBER: 405850354
VISIT DATE: 05/06/2026
NARRATIVE
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On the allegation: Licensee does not ensure all toilets are clean. Witness stated a toilet was dirty. LPA toured the facility and observed the main bathroom was clean and sanitary, residents bathroom 2 was clean and sanitary, shared resident bathroom 3 had a urine odor and was not clean and sanitary. Based on LPA observation this allegation is Substantiated at this time.

Exit interview conducted, deficiencies cited, copy of report and appeal rights emailed to Administrator per request.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20260501093143
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA GARDENS
FACILITY NUMBER: 405850354
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2026
Section Cited
CCR
87468.1(a)(6)
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(a)... (6)To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night....This requirement was not met as evidenced by:
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Administrator agreed to have the locked removed and the door knob to be re-installed with the lock on the inside of bedroom 5, statement from Licensee that residents will never be locked in rooms and training for all staff on regulation 87468.1 and 87468.2 provide proof of staff training with Lic. 500 to CCL.
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Based on interview and observation the Licensee did not comply with the regulation above in the residents door has a lock placed on the outside of the door to be locked when a resident is in the room which poses an immediate health, safety and personal rights risk to residents in care.
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Type B
05/06/2026
Section Cited
CCR
87464(f)(1)
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(f)Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:
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Administrator agreed to write a statement of understanding that staff can not sleep on the job and must be available and awake at all times for resident care. Train staff in 87464, 87705, 87706 and provide proof of training and an up to date LIC. 500 for staff to CCL.
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Based on interviews the Licensee did not comply with the regulation above in the staff on duty was on the couch with eyes closed looked to be sleeping with residents in care which poses a potential health, safety and personal rights risk to 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20260501093143
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA GARDENS
FACILITY NUMBER: 405850354
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2026
Section Cited
CCR
87411(d)(3)
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(d)All personnel shall be given on the job training...This training...shall provide...(3)Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement was not met as evidenced by:
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Administrator agreed to provide all staff training on residents hoyer lift, provide proof of training and up to date LIC. 500 to CCL.
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Based on records the Licensee did not comply with the regulation above in the facility did not have on the job training for staff on resident in cares hoyer lift which poses a potential health, safety and personal rights risk to residents in care.
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Type B
05/13/2026
Section Cited
CCR
87307(a)(3)(D)
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(a)...The following provisions shall apply: (3)Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident....(D)Hygiene items of general use such as soap and toilet paper. This requirement was not met as evidenced by:
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Based on interviews and observation the Licensee did not comply with the regulation above in the Staff removed toilet paper from the restrooms so a resident would not continue to clog the toilets which poses a potential health safety and personal rights risk to residents in care.
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Administrator agreed to talk with residents doctor and get a update LIC 602A if it is a safety risk for resident to have personal grooming and hygiene items. Train all staff on regulation 87307 and provide proof of training and up to date LIC. 500 to CCL.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20260501093143
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLA GARDENS
FACILITY NUMBER: 405850354
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2026
Section Cited
CCR
87303(a)
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(a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Administrator agreed to clean the facility so no odor if urine is present make sure all sink and toilets are clean, safe and sanitary for the residents in care, train all staff in regulation 87303 and provide proof of training with an up to date LIC. 500 to CCL.
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Based on interviews and observation the Licensee did not comply with the regulation above room 5 bedroom bathroom had an odor of urine, the sink and floor were in need of cleaning which poses a potential health, safety and personal rights risk to 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6