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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006204
Report Date: 05/16/2023
Date Signed: 05/16/2023 03:05:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/14/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230414121958
FACILITY NAME:WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVINGFACILITY NUMBER:
306006204
ADMINISTRATOR:ESPINAL, ALMAFACILITY TYPE:
740
ADDRESS:2025 N BUSH STTELEPHONE:
(714) 541-3357
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY:130CENSUS: 65DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Alma EspinalTIME COMPLETED:
03:28 PM
ALLEGATION(S):
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Staff is overcharging resident in care
Staff does not provide an itemized list of financial costs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the complaint investigation, LPA toured the facility, interviewed staff, resident, and witnesses as well as reviewed and obtained pertinent documentation such as physician report and facility correspondence. Regarding the allegation that staff is overcharging resident, the investigation revealed the following: Resident 1 (R1) admitted into the facility on 03/09/2023. Interview conducted with facility indicated resident was charged for the month of March and did not prorate for the prior eight days not admitted into facility. After discussion with facility regarding the fee, facility provided a refund to the resident for $353. LPA reviewed admission agreement during the investigation. Admission agreement does not indicate the basic service rate under "Rate for basic services" or "Payment provisions." Admission agreement indicated a total price without a breakdown of resident's SSI rate. The preponderance of evidence standard has been met, therefore the above allegations is found to be SUBSTANTIATED. CONTINUED ON LIC 9099C DATED 06/16/2023
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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 6
Control Number 22-AS-20230414121958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVING
FACILITY NUMBER: 306006204
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/11/2023
Section Cited
CCR
87468.2(a)(8)
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In addition to the rights listed in Section 87468.1.. residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: To be free from.., financial exploitation, involuntary seclusion, punishment, humiliation, intimidation...This requirement is not being met as evidenced by:
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Licensee provided a refund to resident in the amount of $353 and provided proof to LPA. CLEARED DURING VISIT.
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Based on interviews conducted, Licensee failed to ensure resident was charged properly for rent. R1 admitted into the facility on 03/09/2023 and was charged for the whole month of March. This poses a potential health and safety risk to residents in care.
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Type B
05/30/2023
Section Cited
CCR
87507(g)(3)(A)
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Admission agreements shall specify the following: Payment provisions, including the following: Rate for all basic services which the facility is required to provide in order to obtain and maintain a license... This requirement is not being met as evidenced by:
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Licensee to complete admission agreement and forward completed agreement to LPA and responsible party by POC due date.
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Based on record review, Licensee failed to ensure admission agreement specified payment provisions including basic service rate. This poses a potential health and safety risk to resident's 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 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, 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
04/14/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230414121958

FACILITY NAME:WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVINGFACILITY NUMBER:
306006204
ADMINISTRATOR:ESPINAL, ALMAFACILITY TYPE:
740
ADDRESS:2025 N BUSH STTELEPHONE:
(714) 541-3357
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY:130CENSUS: 65DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Alma EspinalTIME COMPLETED:
03:28 PM
ALLEGATION(S):
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Facility's emergency disaster plan is out of date.
Staff do not answer facility phone.
Staff does not schedule resident's medical appointments as needed
Staff does not communicate with responsible party
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the complaint investigation, LPA toured the facility, interviewed staff, resident, and witnesses as well as reviewed and obtained pertinent documentation such as physician report and facility correspondence. Regarding the allegation that facility's emergency disaster plan is out of date, staff do not answer facility phone, staff does not communicate with responsible party and staff does not schedule resident's medical appointments as needed, the investigation revealed the following: LPA observed a posted emergency disaster plan posted prominently in the facility. The plan observed was up to date and complete. LPA called the facility telephone on multiple occasions including after hours. The phone was answered promptly and without issue. Facility indicates a 24 hour answering service to assist in communication for families and staff. Any calls made will go through the service and be forwarded to the appropriate party. Lead staff maintain a cell phone after hours to ensure all calls are answered. CONTINUED ON LIC 9099C DATED 06/16/2023
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 22-AS-20230414121958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVING
FACILITY NUMBER: 306006204
VISIT DATE: 05/16/2023
NARRATIVE
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LPA observed staff at the front desk on two different occasions and spoke with front office reception, Per facility, R1's family member notified facility on 04/13/2023 of resident's need for an eye doctor appointment. As R1 has an HMO for insurance, facility reached out to a primary care doctor for a referral to an eye doctor. Referral was received and an appointment was scheduled for 05/03/2023. Resident declined to go to the appointment. Resident moved into the facility on 03/09/2023 as self responsible. Facility received a DPOA for financial purposes on 04/11/2023. Facility responded to DPOA's requests on 04/17/2023. DPOA does not have responsibility for anything healthcare or medically related and facility was under no obligation to respond to any requests other than financial concerns. With the resident's permission, facility provided documents not related to finances on 04/17/2023. Therefore, the allegations are deemed UNFOUNDED, meaning the allegations were false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was emailed to Administrator.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20230414121958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVING
FACILITY NUMBER: 306006204
VISIT DATE: 05/16/2023
NARRATIVE
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California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report was provided to facility administrator via email along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 5 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, 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
04/14/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230414121958

FACILITY NAME:WILLOW VIEW GARDENS MEMORY CARE & ASSISTED LIVINGFACILITY NUMBER:
306006204
ADMINISTRATOR:ESPINAL, ALMAFACILITY TYPE:
740
ADDRESS:2025 N BUSH STTELEPHONE:
(714) 541-3357
CITY:SANTA ANASTATE: CAZIP CODE:
92706
CAPACITY:130CENSUS: 65DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Alma EspinalTIME COMPLETED:
03:28 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not provide resident with necessities for bedroom
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the complaint investigation, LPA toured the facility, interviewed staff, resident, and witnesses as well as reviewed and obtained pertinent documentation such as physician report and facility correspondence. Regarding the allegation that staff does not provide resident with necessities for bedroom, the investigation revealed the following: Facility states providing all bedroom and hygiene necessities to resident. LPA toured R1's room and observed all required items. Facility indicates swapping the resident's dresser out for a larger one once resident's belongings were moved in by APS. LPA observed R1's roommate was missing a lamp which was provided during the visit. R1 stated satisfaction with supplies and verbalized everything was provided to the resident. Due to conflicting information, LPA is unable to corroborate the allegation. Therefore, the allegation is deemed unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted and a copy of this report was provided to facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 6