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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881251
Report Date: 07/05/2022
Date Signed: 11/04/2022 09:27:58 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
06/28/2022 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220628120253
FACILITY NAME:WESTHILLS VILLA GARDENSFACILITY NUMBER:
331881251
ADMINISTRATOR:ESPINAL, ALMAFACILITY TYPE:
740
ADDRESS:5466 WEST WILSON ST.TELEPHONE:
(951) 849-7521
CITY:BANNINGSTATE: CAZIP CODE:
92220
CAPACITY:30CENSUS: 19DATE:
07/05/2022
UNANNOUNCEDTIME BEGAN:
11:28 AM
MET WITH:Maria Jasmin DoloresTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff did not prevent residents from wandering away from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced visit to the facility for the purpose of initiating an investigation and delivering findings for the above complaint allegation. LPA Gardner met with Assistant Maria Jasmin Dolores and explained the reason for the visit. At the time of the visit, there were nineteen (19) residents, and four (4) staff present.

During today’s visit, LPA Gardner toured the facility, interviewed staff members, interviewed a resident, and reviewed facility records.

For allegation, Staff did not prevent residents from wandering away from the facility:

LPA Gardner found that resident R1 left the facility on 6/20/2022 without staff’s knowledge. The staff at the facility received a phone call from R1’s responsible party to inform staff that R1 had been found at an alternative location by a police officer.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022
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-20220628120253
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: WESTHILLS VILLA GARDENS
FACILITY NUMBER: 331881251
VISIT DATE: 07/05/2022
NARRATIVE
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LPA Gardner received R1’s physician’s report that states R1 has wandering behaviors. LPA Gardner received R1’s Resident Admission Appraisal that states R1 needs special observation at night because resident will leave. R1 lives in a cottage building behind the main facility building that requires staff to leave the main building to check on the resident. The day the incident occurred the resident went over two (2) hours without staff checking on the resident. The facility did not put additional safety measures in place to ensure R1 was safe due to R1's wandering behaviors.

Based on the information found and provided, the allegation listed above 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 Assistant Maria Jasmin Dolores, along with a copy of the appeal rights.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20220628120253
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: WESTHILLS VILLA GARDENS
FACILITY NUMBER: 331881251
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/06/2022
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 self-certify letter that the regulation was read and understood. The licensee has agreed to put a plan in place to ensure the resident’s wandering behaviors are addressed and the resident is safe. The plan needs to be written in a letter and sent to LPA.
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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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CCR
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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: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022
LIC9099 (FAS) - (06/04)
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