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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881248
Report Date: 01/04/2023
Date Signed: 01/04/2023 12:07:47 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2022 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20221228092218
FACILITY NAME:WESTFIELD VILLA GARDENSFACILITY NUMBER:
331881248
ADMINISTRATOR:MARIA JASMIN DOLORESFACILITY TYPE:
740
ADDRESS:3863 WEST RAMSEY STTELEPHONE:
(951) 849-7521
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:50CENSUS: 27DATE:
01/04/2023
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Gemma Falls- Support Staff TIME COMPLETED:
12:20 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident leaving the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to the facility for the purpose of initiating an investigation and delivering findings for the above complaint. LPA Allen met with Gemma Falls and she was informed of the reason for the visit.

During today’s visit, LPA Allen toured the facility, interviewed five (5) staff members,one (1) outside party and reviewed resdients records.

Staff did not provide adequate supervision resulting in resident leaving the facility.

LPA Allen found that Resident (R1) did leave the facility on12/24/2022 without staff’s knowledge. Staff was going to direct (R1) to the dinning area so lunch could be served that is when the staff member noticed that the resident was missing which was around 11:30AM. Gemma immediatley called Banning Police Department, (R1's) responsible party, and notified CCL Department.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
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 3
Control Number 56-AS-20221228092218
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: WESTFIELD VILLA GARDENS
FACILITY NUMBER: 331881248
VISIT DATE: 01/04/2023
NARRATIVE
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The facility staff was notified by Banning Police Department within 1 hour that (R1) was located near the facility and was transferred to RUSH. LPA Allen reviewed (R1’s) admission appraisal/ physician’s report that states (R1) has wandering and confused/disoriented behaviors.

Based on interviews and record review the allegation is deemed Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
During today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Gemma Falls- Support Staff, along with a copy of the appeal rights at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20221228092218
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: WESTFIELD VILLA GARDENS
FACILITY NUMBER: 331881248
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/05/2023
Section Cited
CCR
87705(b)(2)
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87705.Care of Persons with Dementia.
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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The licensee has agreed to read regulation 87705 entirely and send LPA letter stating that the regulation was read and understood. The licensee has agreed to put a plan in place to ensure that resident’s with wandering behaviors are addressed and residents in care are safe. sent to LPA by the POC date 1/5/2022.
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This requirement was not met based on evidence by interview, observation, and document review. The licensee did not comply with the section cited above by not having safety measures in place to keep dementia resident with wandering behaviors safe which poses an immediate health, safety or personal rights risk to persons 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: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3