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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881248
Report Date: 10/12/2023
Date Signed: 10/12/2023 09:41:56 AM

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
07/28/2023 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20230728141845
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: 31DATE:
10/12/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Maria Jasmin Dolores-AdministratorTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Staff relocated residents to facility without their consent.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the mentioned allegations. LPA Allen met with Maria Jasmin Dolores-Administrator who was informed of the purpose of the visit.

The investigation consisted of interviews with three (3) clients,three (3) responsible parties and a review of each client’s file. The interviews with the clients and their responsible parties all stated the clients were removed from Arlington Riverside Senior Community and relocated to Westfield Villa Gardens without their consent. However, the clients have all stated they are willing to remain where they are currently. During the investigation Maria J. Dolores was asked if the clients and their responsible parties were aware of the move to Westfield Villa Gardens and she stated that she could not confirm or deny that consent was given because she never confirmed with the clients, their responsible parties or the administrator because she was under the impression consent was given prior to the relocation.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
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-20230728141845
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: 10/12/2023
NARRATIVE
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Based on file review and interviews with the staff, clients, and outside parties the allegations findings are Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

A deficiency is being cited on the attached LIC 9099-D.

An exit interview was conducted where this report was discussed, and a copy was provided to Maria Jasmin Dolores- Administrator at the conclusion of the visit with appeal rights.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Citations on this Visit Report are Under Appeal!

Control Number 56-AS-20230728141845
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: 10/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
10/13/2023
Section Cited
CCR
87468.2(a)(20)
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Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:To be protected
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The licensee has agreed to provide staff training regarding the cited CCR and write a written statement of understanding signed by all staff members by the POC date of 10/13/23 by fax 951-248-0370.
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from involuntary transfers, discharges, and evictions A licensee shall not involuntarily transfer or evict ....This requirement is not met as evidenced by: Based on the interviews with staff & clients the licensee did not ensure clients were protected from an involuntary transfer.
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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: 10/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3