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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 405850354
Report Date: 06/17/2026
Date Signed: 07/01/2026 11:46:56 AM

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
06/17/2026 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20260617080150
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: DATE:
06/17/2026
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Lizbeth Tunac, Back up to AdministratorTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff did not meet resident’s needs
Facility is unsanitary
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 Lizeth Tunac, Assitant Administrator/LVN and explained the purpose of the visit.

LPA toured the facility and spoke with all 4 residents and 2 staff from 10:30am-11:00am.
LPA requested a staff roster, resident roster, All 4 residents care plans and LIC 602A medical assessments, and staff Schedule for June 2026. LPA called Licensee/Administrator, no one answered, LPA left a text message for Licnesee to return call.

On the allegation: Facility is unsanitary. LPA interviewed witnesses which revealed a resident had a soiled washcloth left by the resident’s head after staff cleaned up resident in bed. Witness also stated a hospice aide came to bathe a resident in care and when going to the resident’s drawer to get clean briefs found a soiled brief with clean briefs in drawer. Continued 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
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-20260617080150
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: 06/17/2026
NARRATIVE
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LPA observed facility to be clean at the time of visit but the hallway to the resident’s room had an odor of urine. Witnesses also stated a resident’s bed linens have not been changed for several weeks. LPA observed all residents’ beds, several of them did not have the required linens in place and 2 of the beds had dirty blankets and linens.
Based on the evidence this allegation is Substantiated at this time.

On the allegation: Staff did not meet resident’s needs. LPA interviewed Witness which revealed witness came to visit and found R1 in bed in the flat laying position with a sandwich in hand and no staff present. LPA interviewed staff member which revealed R1 does need assistance with feeding. LPA observed staff feeding R1 at lunch time, R1 was up in wheelchair in the patio area at lunch time.

LPA reviewed Resident 1 (R1) records which revealed R1 is on hospice services, needs 2 person assist, according the R1’s LIC 602A dated 01/21/2026 R1 is not able to bath, dress or groom self, is incontinent in bladder and bowels, requires assistance with repositioning and transfers, on a special diet due to Dysphagia, and able to feed self but needs staff monitoring.

Based on the evidence this allegation is Substantiated at this time.

Exit interview completed, deficiencies cited and copy of report printed for Assistant Administrator/LVN.


SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20260617080150
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: 06/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2026
Section Cited
CCR
87464(f)(4)
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(f)... (4)Personal assistance and care as needed by the resident...with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications,...This requirement was not met as evidenced by:
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Administrator is to make sure all R1’s forms are up to date to give a full account of R1’s current needs and services, provide a letter of understanding of R1’s needs and how the facility will meet R1’s needs. Train staff on regulation 87464 and provide proof of training to CCL.
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Based on interviews the Licensee did not comply with the regulation above in R1 was not monitored while eating which poses an immediate health, safety and personal rights risk to residents in care.
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Type B
06/24/2026
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 and disinfect the residents rooms, have a trash can and a laundry hamper aviable for dirty items, provide clean linens on each bed,all linens meeting regulation requirements. Train all staff on regulations 87303 and 87470 and provide proof of training to CCL.
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Based on interviews and observation the Licensee did not comply with the regulation above a dirty washcloth was left on residents bed, a dirty brief was left in the drawer with clean briefs, the bed linens were not clean and the facility had a odor of urine in the hallway which possess 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: 06/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
06/17/2026 and conducted by Evaluator Rachael De Leon
COMPLAINT CONTROL NUMBER: 29-AS-20260617080150

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:
06/17/2026
UNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Lizeth Tunac, Asstistant Administrator/LVNTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Insufficient staff
Facility does not have designee for Administrator
Staff locked resident in their room
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 Lizeth Tunac, Assitant Administrator/LVN and explained the purpose of the visit.

LPA toured the facility and spoke with all 4 residents and 2 staff from 10:30am-11:00am.
LPA requested a staff roster, resident roster, All 4 residents care plans and LIC 602A medical assessments, and staff Schedule for June 2026. LPA called Licensee/Administrator, no one answered, LPA left a text message for Licnesee to return call.

On the allegation: Insufficient staffing. LPA interviewed 4/4 residents which revealed the facility has staff and residents are fine or good at this time. LPA observed all 4 residents eating lunch.
A resident stated resident is fine, gets care, supervision and meals from staff, and the staff are good.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20260617080150
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: 06/17/2026
NARRATIVE
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Another resident stated the meals are good, the staff help with re-positing and turning in bed, staff help residents with cleaning up and wiping down, the staff are the residents’ favorite people and LPA observed the resident was changed and cleaned up by staff member and brought out in wheelchair to eat lunch on the patio and was feed by staff.
Another resident could not answer LPA questions due to dementia diagnosis. LPA observed the resident, was clean and groomed properly, walking around facility, watching TV, playing with a hand towel and eating lunch at the dining room table.
A hospice resident was in bed, said resident was doing fine and had no problems, thank you for checking, resident was changed and cleaned up, put in wheelchair by staff and brought out to lunch at the dining room table.
LPA observed 2 staff working at the facility upon arrival. One staff member was providing resident care, filling in for the Administrator for a few weeks while out of town and provided LPA with all the requested resident records. The other staff member cleaned the kitchen, was prepping and cooking food for lunch and serving lunch to the residents in care. Staff stated they help each other when residents are needing transfers or repositioning in bed.
Staff stated the facility has several other staff to work shifts. According to the LIC 500 dated June 2026 the facility has a total of 1 Administrator/ LVN works weekday 7am-7pm shifts, 1 Assistant Administrator/LVN works weekday shifts 7am-7pm , 1 Housekeeper/Cook/Aide works weekday 7am-7pm shifts, 1 CNA works weekend shifts 7am-7pm, 1 awake caregiver for weekday 7pm-7am shifts, 1 RN works weekend Sat/Sun 7am-7pm shifts, 1 awake caregiver works Sat/Sun 7pm-7am. According to the staff present this is a good schedule for what the staff is currently working at the facility.
A witness stated the facility is not properly staffed with enough staffing that is knowledgeable and able to care for others. There is a staff member present that is only supposed to do housekeeping and cooking with no resident care provided but feels this staff is doing caregiving at the facility and is worried about the residents in care. The Witness stated an LVN staff is working at the facility and provides good care but also has another job so not sure of the working hours but was told by the Administrator the LVN would be covering shifts while Administrator was out of town. The Administrator has left the facility to go out of town due to being overwhelmed. The Witness does not know what staff is covering overnight shifts and does not know if the facility is providing awake staff overnight coverage..

Based on the lack of evidence this allegation is Unsubstantiated at this time.
Continued 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20260617080150
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: 06/17/2026
NARRATIVE
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On the allegation: Facility does not have designee for Administrator. LPA interviewed LVN/Assistant Administrator which revealed the administrator is out of town on vacation and is covering the administrator day shifts while administrator is gone for 2 weeks. Facility documents did not reveal LIC. 308 Designation on file for the staff member covering the administrator on record. The staff covering for Administrator was able to provide LPA will all the records requested. The covering staff is on the LIC 500 Personnel Report listed as Assistant Administrator/LVN working Monday -Friday 7am-7pm, therefore this allegation is Unsubstantiated at this time.

On the allegation: Staff locked resident in their room. LPA toured the facility and took photographs of the resident’s three bedroom doors, only room 3 has a lock on the door, and it is placed correctly that the residents can lock the room and unlock the room from the inside and cannot be locked in the room from the outside, the room is a double room occupying 2 residents in care, and both residents are verbal, 1 of tne resident in Non-Ambulatory and has a wheelchair, the other resident is Ambulatory and able to move around the facility. Witness interview revealed the resident in room 3 was able to go out the sliding glass door on to the patio but went to Room 1 patio door and knocked, a family member was present with resident in Room 3 and opened the door for the other resident, when the resident entered the room the resident laid down in another residents bed and had to be redirected by staff. The residents were not locked in rooms, 2 residents can move freely around the facility while the other 2 residents need transfers to wheelchairs to be able to move around the facility. LPA observed staff doing transfers and bringing both residents out of rooms for lunch. Based on the lack of evidence this allegation is Unsubstantiated at this time.

Exit interview conducted and copy of report printed for Assistant Administrator/LVN.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6