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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603439
Report Date: 04/18/2024
Date Signed: 04/18/2024 03:53:15 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
04/10/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240410124456
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: 6DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Henny Patiradjawane, staffTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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1. Staff locked resident in bedroom.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced and met with staff, Jermin Henny Patiradjawane. The purpose of the visit was explained.

The investigation consisted of the following:
LPA toured the facility, reviewed files, and interviewed staff and residents. The administrator was interviewed via telephone. 2 Staff (S1 – S2) and 5 Residents (R1 – R5) were interviewed at the facility.

The investigation revealed the following:
Allegation - Staff locked resident in bedroom. It is alleged that Resident #1's (R1) door could not be opened from inside. LPA interviewed the administrator and staff who denied locking the resident in the room. They stated the door was propped open all the time so resident could go in and out.
(continue on next page)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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 28-AS-20240410124456
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: 04/18/2024
NARRATIVE
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The administrator stated that the resident had a key to unlock the door but lost it. Interviews with staff and witnesses revealed that R1 had tried to leave the facility unsupervised several times. LPA obtained a video footage of R1's previous door. It showed that the keyhole was placed inside of the room and was locked. R1 would need to use a key to unlock the door or someone from the outside would need to open the door. R1 would pound on the door because the door could not be opened from the inside. Staff would immediately open the door when R1 called out. Witnesses stated that while they were in R1's room and closed the door, they could not get out. Administrator and Staff acknowledged that the door knob was recently changed.

Based on LPA observations and interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Corrections were reviewed and developed with the licensee via telephone. A copy of this report and appeal rights were given to the staff.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20240410124456
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: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2024
Section Cited
CCR
87468.1(a)(6)
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87468.1 Personal Rights of Residents in All Facilities
(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 is not met as evidenced by:
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The licensee shall ensure the residents can leave its room anytime. The lock shall be changed in Resident #1's room so that he/she can go in and out.

**POC has been cleared as of today.***
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Based on observation and interviews, Resident #1's room could not be opened on the inside without a key which poses a 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.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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
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
04/10/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240410124456

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: 6DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Henny Patiradjawane, staffTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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1. Resident bedroom is cold.
2. Staff do not meet resident’s needs.
3. Resident's nutritional needs are not being met.
4. Facility failed to safeguard resident's belongings.
5. Facility is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced and met with staff, Jermin Henny Patiradjawane. The purpose of the visit was explained.

The investigation consisted of the following:
LPA toured the facility, reviewed files, and interviewed staff and residents. The administrator was interviewed via telephone. 2 Staff (S1 – S2) and 5 Residents (R1 – R5) were interviewed at the facility.

The investigation revealed the following:
1. Allegation - Resident bedroom is cold. During the visit today, LPA interviewed staff and residents. The administrator and staff stated that they provide the residents with a portable heater in their rooms. LPA toured the facility and observed portable heaters in each of the resident’s room.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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 28-AS-20240410124456
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: 04/18/2024
NARRATIVE
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 5 of the residents interviewed stated they use the heater when it is needed. When they ask the staff to turn it on, staff would assist. They stated the bedroom is at a comfortable temperature.

2. Allegation - Staff do not meet resident’s needs. It is alleged that the staff do not shower the resident. Staff interviewed stated they provide bed baths to residents daily. Staff stated Resident #1 (R1) does not want staff to shower and prefers to do it himself/herself. R1 is independent and can shower, dress, and use the toilet on own. LPA interviewed 5 residents. One of the residents stated he/she can do their own activities of daily living, while the other 4 stated that staff assist them with toileting and dressing when needed. Staff cleans them and provides bed baths daily.

3. Allegation - Resident's nutritional needs are not being met. It is alleged that facility does not serve nutritious food to residents. For example, the resident is served a hotdog and eggs for breakfast and sweets for dinner. LPA interviewed staff who indicated that they make the residents’ meals based on their preference. They ask the residents what they would like to eat and then make their food. None of the residents have a restricted diet but would cook food that are softer for consumption. They provide meat and vegetables in the meals. 4 out of the 5 residents interviewed stated the food is ok and are provided with different meats and vegetable. LPA observed a variety of meats, vegetables, and fruits in the refrigerator during the visit today.

4. Allegation - Facility failed to safeguard resident's belongings. It is alleged that Resident #1 (R1) lost a denture and a computer. The administrator stated that R1 did not have any items upon admission except for dentures. Staff acknowledged R1 wears dentures and were informed that R1 lost them recently. R1 could not recall if it was thrown away by mistake. One of the staff remembers seeing R1 with a computer but stated R1 has not used it since. Staff denied taking any of R1’s belongings. Staff stated R1 gets visitors often and do not know if the visitors took it with them. R1 had misplaced things in the past but was later found. The facility does not have a resident’s personal inventory safeguarding form for this individual. Based on the information gathered, there is insufficient evidence to prove that the facility is responsible in safeguarding the resident’s belongings.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20240410124456
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: 04/18/2024
NARRATIVE
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5. Allegation – Facility is in disrepair. It is alleged that the t.v. is not working in R1’s room. LPA toured the facility and observed all the televisions working. R1 stated that the t.v works but is not sure how to use the controller. Staff indicated that the television was never broken and said that R1 has trouble using the remote. The other residents stated their t.v. works fine and have no issues with it.

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 with the licensee via telephone. A copy of this report along with the appeal rights were given to the staff.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6