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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603439
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:25:42 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/06/2023 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230106135228
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:
01/12/2023
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Jermin Pattiradjawane - CaregiverTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility is in disrepair.
Facility staff are not ensuring that residents' clothes are getting cleaned and dried.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Jermin Pattiradjawane (Caregvier) and explained the reason for the visit.

The investigation consisted of the following: LPA interviewed Administrator, Staff 1 (S1) and Resident 1 - Resident 3 (R1 - R3). LPA conducted a tour of the facility and tested the dyer.

The investigation revealed the following: regarding the allegation "facility is in disrepair", it is alleged that there was a hole in the living room's ceiling. Interview with administrator and staff confirmed that there was a hole in the living room's ceiling and it was repaired on 01/06/2023. The hole has been there for 3-4 months. A picture of the hole that was taken on 01/05/2023 was submitted to LPA as proof.
(CONTINUED TO LIC 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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 5
Control Number 28-AS-20230106135228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VILLA VICTORIA
FACILITY NUMBER: 198603439
VISIT DATE: 01/12/2023
NARRATIVE
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Regarding the allegation "facility staff are not ensuring that residents' clothes are getting cleaned and dried", it is alleged that the facility's dryer is not working and due to the lack of a working dryer it has impacted the resident's ability to have clean clothes. Interview with administrator and staff revealed that the dryer does turn on, but it is not heating properly so the clothes are not getting dried. The clothes is hung outside and once it is damp then they put it in the dryer. The dryer will dry damp clothes only. However, LPA tested the dryer by putting a damp rag inside the dryer and running a cycle on high heat for about 45 minutes. At the end of the cycle the rag was still damp.

Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegations are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099D. Exit interview held and a copy of the report and appeal rights was provided
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230106135228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA VICTORIA
FACILITY NUMBER: 198603439
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(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 is not met as evidence by:
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Facility is to ensure that Title 22 Section 87303 regulations are met at all times. Additionally, a statement indicating facility understands and will comply with Title 22 Section 87303 will be submitted to CCLD by 01/20/2023.

Hole was repaired on 01/06/2023.
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Based on interviews, observation and records reviewed the licensee did not comply with the section cited above which poses a potential risk to the health, safety, or personal rights of the persons in care. There was hole in the living room's ceiling for 3-4 months.
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Type B
01/20/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(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 is not met as evidence by:
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Facility is to ensure that Title 22 Section 87303 regulations are met at all times. Additionally, facility will repair or replace the dryer and submit proof to CCLD by 01/20/2023.
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Based on interviews, observation and records reviewed the licensee did not comply with the section cited above which poses a potential risk to the health, safety, or personal rights of the persons in care. The dryer is not working.
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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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
01/06/2023 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230106135228

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:
01/12/2023
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Jermin Pattiradjawane - CaregiverTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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2
3
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5
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9
Staff are not maintaining facility at a comfortable temperature for the residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced complaint visit to determine the validity of the above-mentioned allegations. LPA met with Jermin Pattiradjawane (Caregvier) and explained the reason for the visit.

The investigation consisted of the following: LPA interviewed Administrator, Staff 1 (S1) and Resident 1 - Resident 3 (R1 - R3). LPA conducted a tour of the facility and tested the dyer.

The investigation revealed the following: regarding the allegation "staff are not maintaining facility at a comfortable temperature for the residents", it is alleged that facility has no working central heating and that the facility gets cold. Interviews with administrator revealed that the central heating unit should be working and it is set at 72 degrees. It will automatically turn ON and OFF once the facility reaches 72 degrees. Residents interviewed could not corroborate the allegation. LPA observed that the central heating unit is working and the thermostat showed a temperature of 72 degrees. (CONTINUED TO LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
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 5
Control Number 28-AS-20230106135228
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: VILLA VICTORIA
FACILITY NUMBER: 198603439
VISIT DATE: 01/12/2023
NARRATIVE
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Additionally, all residents have a space heater in their bedrooms. All residents stated that these heaters keep them warm during the cold weather. During the visit, the LPA felt a comfortable warm temperature throughout the facility.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations is unsubstantiated.

Exit interview held and a copy of the report was provided
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5