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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006204
Report Date: 02/19/2025
Date Signed: 02/19/2025 11:07:11 AM

Unsubstantiated


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
09/12/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240912142400
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: 82DATE:
02/19/2025
UNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Tony RuizTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Resident sustained unexplained injuries due to lack of supervision
Resident sustained unwitnessed fall due to lack of supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit on this day for the purposes of delivering findings into the above allegation. On this day, LPA was greeted and met with Maintenance Director Tony Ruiz.
On September 12, 2024, the Department received a complaint alleging Resident sustained unexplained injuries due to lack of supervision; Resident sustained unwitnessed fall due to lack of supervision; and Facility staff did not dispense medications as prescribed. A health and safety visit was conducted by the Department on September 13, 2024, and an investigation initiated. The investigation determined as follows:
Resident 1 (R1) was admitted to the facility on August 07, 2024. Per Physician Report dated August 07, 2024, R1 has a diagnosis of generalized weakness and Alzheimer’s disease and requires some assistance with activities of daily living (ADLs) such as bathing, toileting, and dressing. Per Physician Report, R1 requires 24-hour monitoring due to cognitive impairment and impaired functional mobility. R1’s pre appraisal plan dated August 13, 2024, notates R1 cannot walk long distances due to prior broken hip. Continued on LIC 9099C dated 02/19/2025
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
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-20240912142400
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: 02/19/2025
NARRATIVE
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On September 11, 2024, R1 was found by Staff 1 (S1) at approximately 1 PM laying on their bedroom floor. S1 reported they had heard R1 calling for help prompting their response. Upon finding R1, facility staff sought emergency medical services. R1 reported they were attempting to reach for their walker when they fell. S1 reported last observing R1 at 12PM, approximately an hour earlier, when they had passed out medications. Upon being admitted to Norwalk Community Hospital, R1 was diagnosed with facial contusions, knee abrasions and forehead hematoma. R1 reported to hospital staff they had fallen after reaching for a napkin. Due to inconsistency in R1’s report and injuries observed, Santa Ana Police arrived to speak with R1. Per Santa Ana Police report, R1’s injuries appeared consistent with injuries sustained from a fall. R1 reported being beaten by “four women” but was unable to provide further elaboration. The Department attempted a separate interview with R1 but was unable to due to R1’s cognitive decline. R1 did not appear oriented to time and space.

Interviews with four of four staff reported R1 was independent prior to fall and received hourly to bi-hourly checks. Staff reported being aware R1 was a fall risk. The facility provided R1 with a fall matt and a call light to ask for assistance when needed. Interviews with R1’s nurse practitioner revealed no concerns of neglect. Per interview with R1’s responsible party, no concerns with R1’s care were expressed.

Based on interviews conducted and records reviewed, the allegations that Resident sustained unexplained injuries due to lack of supervision and Resident sustained unwitnessed fall due to lack of supervision is deemed to be Unsubstantiated. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred. This agency has investigated this complaint.

An exit interview was conducted and a copy of this report and confidential names list was provided to facility representative.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 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
09/12/2024 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20240912142400

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: 82DATE:
02/19/2025
UNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Tony RuizTIME COMPLETED:
11:35 AM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Facility staff did not dispense medications as prescribed
INVESTIGATION FINDINGS:
1
2
3
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5
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13
Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit on this day for the purposes of delivering findings into the above allegation. On this day, LPA was greeted and met with Maintenance Director Tony Ruiz and explained the reason for the visit.
During the course of the investigation, the department interviewed staff as well as reviewed and obtained pertinent documentation such as medication orders. Regarding the allegation that facility staff did not dispense medications as prescribed, the investigation revealed the following: R1 was prescribed Oxycodone 5/325 1 tab every 6 hours as needed and Norco 5/325 8 1 tab every 8 hours as needed. Facility documentation indicates resident was receiving the prescribed medication as needed. Based on interviews conducted and record review, the allegation is deemed unfounded, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this report was provided to facility representative.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3