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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881248
Report Date: 03/28/2024
Date Signed: 03/28/2024 01:56:51 PM

Unsubstantiated


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
03/21/2024 and conducted by Evaluator Melody Brown
COMPLAINT CONTROL NUMBER: 56-AS-20240321085554
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:
03/28/2024
ANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Maria Jasmin DoloresTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not provide adequate supervision, resulting in a resident being threatened by other residents.
Staff did not ensure that a resident received medical services.
Staff left a resident in a wheelchair for extended periods of time.
INVESTIGATION FINDINGS:
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On 03/28/2024 at 01:30 PM, Licensing Program Analysts (LPAs) Melody Brown and Sarina Ramirez met with Administrator Maria Jasmin Dolores at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegations. LPAs Brown and Ramirez explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The first allegation indicates that Staff did not provide adequate supervision, resulting in a resident being threatened by other residents. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with four (4) of four (4) residents indicated that all staffs at the facility are providing them adequate supervision and all residents interviewed reported that they did not know of an incident that a resident at the facility was threatened by another resident. LPA Brown unable to interview Resident #1 (R1) as R1 refused to be interviewed. *** Continuation in LIC9099C ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
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 56-AS-20240321085554
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: 03/28/2024
NARRATIVE
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Interviews with six (6) of six (6) staffs indicated that they are all providing adequate supervision to all their residents at the facility, and they all reported that they are all checking on their residents at least every two (2) hours more often if needed. Staffs’ interviews revealed that no incident happened at the facility that a resident was threatened by another resident. Records review indicated that staffs are checking on residents every two (2) hours. During the facility visit on 03/25/2024, LPA Brown observed caregivers checking on residents while doing their rounds.

The second allegation indicates Staff did not ensure that a resident received medical services. Interviews with four (4) of four (4) residents indicated that all staffs at the facility are making sure that they all received their medical services and there's no incident that happened that a staff did not ensure that they did receive their medical services. LPA Brown unable to interview Resident #1 (R1) as R1 refused to be interviewed. Interviews with six (6) of six (6) staffs indicated that all staffs at the facility ensure that all their residents received their medical services, that all residents will go to their medical appointments. All staff interviewed reported that no incident happened at the facility that they did not ensure that a resident will receive their medical service because all of their residents are receiving their medical service on time and per schedule. Records review indicated that staffs at the facility are ensuring that the residents are receiving their medical services.

The third allegation indicates Staff left a resident in a wheelchair for extended periods of time. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with four (4) of four (4) residents indicated that they did not witness a staff at the facility leaving a resident in a wheelchair for extended periods of time. LPA Brown unable to interview Resident #1 (R1) as R1 refused to be interviewed. Interviews with six (6) of six (6) staffs indicated that no staff at the facility leaves a resident on wheelchair for extended periods of time. Interviews with staffs revealed that residents have their set schedule that they follow and their residents participate in the daily activities. Staffs interviewed reported to LPA Brown that there's no incident happened at the facility that a resident was left on a wheelchair for extended period of time. During the visit on 03/25/2024, LPA Brown observed no resident at the facility left on wheelchair by a staff for extended period of time.

*** Continuation in LIC9099C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20240321085554
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: 03/28/2024
NARRATIVE
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Based on the evidence, the allegation that Staff did not provide adequate supervision, resulting in a resident being threatened by other residents (Allegation #1), Staff did not ensure that a resident received medical services (Allegation #2), Staff left a resident in a wheelchair for extended periods of time (Allegation #3) are UNSUBSTANTIATED.

A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted where this report, LIC9099 was discussed and provided to Administrator Maria Jasmin Dolores.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3