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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603439
Report Date: 04/13/2022
Date Signed: 04/13/2022 03:58:04 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/04/2022 and conducted by Evaluator Nune Margaryan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220404131103
FACILITY NAME:VILLA VICTORIAFACILITY NUMBER:
198603439
ADMINISTRATOR:INDRAWATI, YENNYFACILITY TYPE:
740
ADDRESS:1640 S. GLENDORA AVETELEPHONE:
(626) 888-7811
CITY:GLENDORASTATE: CAZIP CODE:
91740
CAPACITY:6CENSUS: 3DATE:
04/13/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Staff Gloria Deguzman and
Administrator Yenny Indrawati		TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Resident's toileting needs are not met
Staff are inaccessible to residents at night
Residents are not assisted in a timely manner
Resident medications are mixed with a liquid without resident consent
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced 10 day complaint visit to investigate the allegations listed above. LPA met with the staff Gloria Deguzman. Shortly after Administrator Yenny Indrawati arrived LPA explained the purpose of the visit.

The investigation consisted of the following: LPA interviewed Resident #1 to Resident #3 (R1 to R3) and Staff #1, Staff #2 (S1, S2) . LPA also reviewed residents files and requested copies of staff and residents roster, and other relevant documentation: Face sheet, Physician's report, Resident Appraisal. Administrator will send requested documents to LPA via email.

Continue 9099C



Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022
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 3
Control Number 28-AS-20220404131103
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VILLA VICTORIA
FACILITY NUMBER: 198603439
VISIT DATE: 04/13/2022
NARRATIVE
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The investigation revealed the following.

In regards to the allegation “Resident's toileting needs are not met”, it was alleged that staff not assisting facility residents with toileting needs and being changed. interviews conducted revealed that staff members assisting residents with toileting needs. S1 and S2 stated residents are orientated and able to call to get assistance with toileting and personal hygrine. Staff helps residents with continent supplies and use the bathroom. Interviewed staff indicated that they check on residents throughout the day and night. Residents are being changed every two hours and as needed. Residents interviewed indicated that staff assist them with toileting needs. Staff and residents interviews were unable to corroborate this allegation.

In regards to the allegation "Staff are inaccessible to residents at night" it was alleged that staff not responding to resident’s call at night. Interviewed staff indicated that they check on residents throughout the day and night. Staff indicated they respond and assist to residents needs in a timely manner. Staff always available at night time and check the residents during the night. Interviewed residents indicated that staff checking on them often and they always get assistance during all day including night time. Staff and residents interviews were unable to corroborate this allegation.

In regards to the allegation "Residents are not assisted in a timely manner", it was alleged that residents left in the soiled diapers at nighttime. Interviewed staff indicated that they check on residents throughout the day and night. Staff will change diapers in a timely manner when checking on the residents at least every 2 hours and making diaper changes if needed at that time or at residents request and there hasn't been any resident observed with soiled diapers. Interviewed residents indicated that staff provide assistance to meet their needs on a timely manner. Staff change their diapers when needed and they are not left in soiled diapers at nighttime. Additionally, residents indicated that when they need assistance, they will ring the bell and staff respond immediately. Staff and residents interviews were unable to corroborate this allegation.

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NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220404131103
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VILLA VICTORIA
FACILITY NUMBER: 198603439
VISIT DATE: 04/13/2022
NARRATIVE
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In regards to the allegation "Resident medications are mixed with a liquid without resident consent", it was alleged that facility staff dropping pill into residents glass of water, instead of handing it to resident with a glass of water to drink. Interviewed staff indicated that they never administer medication by mixing a pill into in water. The medication is administered in a proper way, such as putting the pills in a mini disposable cup and is handed to the residents along with a glass of water. Interviewed residents indicated that staff administrating medication in a proper way. Staff not mixing pills into water or other liquids. Staff and residents interviews were unable to corroborate this allegation.

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.



An exit interview was conducted, and a copy of this report was provided to Staff

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3