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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006204
Report Date: 02/27/2024
Date Signed: 02/27/2024 10:00:52 AM

Unfounded


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
02/15/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240215130307
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: 74DATE:
02/27/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Alma EspinalTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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9
Staff inappropriately placed resident on an involuntary 72hr hold
Staff did not provide resident with keys in a timely manner
Staff are not providing activities for residents
Staff are not allowing resident to leave the facility
INVESTIGATION FINDINGS:
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13
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 investigation, LPA toured the facility, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as psychiatric hospital documentation. Regarding the allegations that staff inappropriately placed resident on an involuntary 72hr hold, staff did not provide resident with keys in a timely manner, staff are not providing activities for residents and staff are not allowing resident to leave the facility, the investigation revealed the following: Resident 1 (R1) was evaluated by a mental health professional on 06/10/2023 due to increaing behaviors and was sent out to LA Downtown Medical Center for a 72 hour hold. Resident was transferred to the medical center as the resident was deemed to have a grave disability per psychiatric paperwork. The resident states being hospitalized for 28 days. R1 has a history of schizoaffective disorder, anxiety, bipolar disorder, depression and psychoactive substance abuse. CONTINUED ON LIC 9099C DATED 02/27/2024
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
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 3
Control Number 22-AS-20240215130307
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: 02/27/2024
NARRATIVE
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Resident did not return to facility after hospitalization. Four out of four staff indicate the resident had a history of losing keys as the resident would leave the facility for weeks at a time. The resident's keys were replaced timely per all staff interviewed and LPA observed the key making machine on-site at the facility as well as all the master keys to be utilized. Facility provides activities to residents and LPA observed residents participating in activities on multiple occasions. Activities are provided in the way of bingo, music therapy and cooking classes and three out of three residents interviewed confirmed activities. Four out of four staff interviewed stated that resident would leave the facility for weeks at a time or would leave in the morning to hang out outside the local 7-11. Staff would not deny the resident to leave facility. Physician report dated 02/23/2023 indicated resident was allowed to leave the facility unassisted. Preplacement appraisal as well as appraisal needs and services indicate resident leaves facility daily. Based on record review and interviews conducted, 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: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
02/15/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240215130307

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: 74DATE:
02/27/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Alma EspinalTIME COMPLETED:
10:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide facility rules to resident
Staff did not provide resident with a copy of his records
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 allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as admission agreement. Regarding the allegations that staff did not provide facility rules to resident and staff did not provide resident with a copy of the resident records, the investigation revealed the following: Interview with Administrator confirmed facility rules as well as a copy of the resident's file had been provided to Resident 1(R1). LPA observed the house rules signed by resident on 02/18/2023. Administrator indicated that residents receive copies of everything they sign at admission. Administrator stated providing a copy of the resident's file when requested by resident after hospitalization. Due to conflicting information, LPA is unable to corroborate the allegations. Therefore, the allegations are deemed unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations 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: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
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 3