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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005256
Report Date: 07/23/2024
Date Signed: 07/23/2024 01:53:37 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/17/2024 and conducted by Evaluator Jerome Haley
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240717091445
FACILITY NAME:HEARTWELL CARE VILLAFACILITY NUMBER:
306005256
ADMINISTRATOR:ALIPIO JR, IRENEO DFACILITY TYPE:
740
ADDRESS:5591 NORMA DRIVETELEPHONE:
(714) 606-1087
CITY:WESTMINSTERSTATE: CAZIP CODE:
92683
CAPACITY:4CENSUS: 3DATE:
07/23/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Davidson AlipioTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff do not adequately supervise resident(s) in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made unannounced visit regarding the complaint allegation above. LPA Haley was greeted, granted entry and explained the reason for the visit before entering the facility. During the visit LPA Haley toured the facility, interviewed staff, residents, witnesses, and collected and reviewed relevant documents.

Regarding the allegation: Staff do not adequately supervise resident(s) in care.

7 of 10 individuals interviewed denied the complaint allegation above. According to multiple staff members and a witness, residents are taken outside to walk around the neighborhood to get fresh air. Witness 4 (W4) stated, usually they have people walking with residents on an exercise walk. According to Staff 1 (S1), Resident 1 (R1) likes to walk around the neighborhood and previously R1 was allowed to walk around the neighborhood alone until R1 fell while walking the neighborhood sometime in 2023.
Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
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 2
Control Number 22-AS-20240717091445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: HEARTWELL CARE VILLA
FACILITY NUMBER: 306005256
VISIT DATE: 07/23/2024
NARRATIVE
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Since R1’s fall, R1 is not allowed to walk alone, and staff walks with R1 when the resident takes neighborhood walks. According to one of the staff members interviewed, the caregiver will observe R1 walking from the porch as the resident walks. R1’s physician’s report dated August 10, 2022, states R1 can leave unassisted, and R1’s updated physician’s report dated October 13, 2023 also states R1 can leave unassisted. However, S1 said after R1’s fall, the physician’s report needs to be updated and changed because R1 no longer leaves unassisted.

Based on the information gathered during the investigation through interviews and document review, the Department is unable to ascertain if the allegation occurred as reported. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violation occurred; therefore, the allegation is deemed Unsubstantiated.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2