335530032-7-29-2025-56-AS-KCLS-DK4TMT-20250731145138

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 335530032
Report Date: 05/26/2023
Date Signed: 07/29/2025 02:56:21 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
05/24/2023 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230524101225

FACILITY NAME:	VILLA DE ANZA		FACILITY NUMBER:	335530032
ADMINISTRATOR:	KATHERINE A. TREVINO		FACILITY TYPE:	740
ADDRESS:	5881 EL PALOMINO DRIVE		TELEPHONE:	(951) 683-3333
CITY:	RIVERSIDE	STATE: CA	ZIP CODE:	92509
CAPACITY:	197	CENSUS: 106	DATE:	05/26/2023
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Patrick McAdoo Morton, Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff did not administer medications as prescribed
Facility is in disrepair.
Facility has insects.
Facility is not serving an adequate amount of food portions to residents.
Facility is unsanitary.
Facility does not have an adequate amount of incontinence supplies for residents
Facility does not have an adequate amount of bedding for residents in care.
Facility is malodorous.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above listed allegations. LPA Prieto met with administrator Morton and explained the elements of the complaint.

Allegation #1 - LPA reviewed Medication Administration Records (MAR) logs for 10 residents and found that medication were being administred as prescribed.

Allegation #2 - The facility is a 3 story, 2 winged facility. LPA toured facilty lobby, outdoor lobby, dinning area, resident activities room, kitchen, library and hallways. LPA found these areas to be functioning and in working order.

Allegation #3 - The facility is a 3 story, 2 winged facility. LPA toured facilty lobby, outdoor lobby, dinning area, resident activities room, kitchen, library and hallways. LPA found these areas to be free from insects.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20230524101225

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: VILLA DE ANZA	FACILITY NUMBER: 335530032
	VISIT DATE: 05/26/2023

NARRATIVE

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The facility obtains the services of an exterminator company that service the facility on a quarter basis and spot treatments when necessary.

Allegation #4 - LPA toured the kitchen area to observe that food being served to be more than adequate in portions. LPA obtained sample menu shows serval options for breakfast lunch and dinner with a variety of choices of food and drinks.

Allegation #5 - The facility is a 3 story, 2 winged facility. LPA toured facility lobby, outdoor lobby, dinning area, resident activities room, kitchen, library and hallways. LPA found these areas to be clean and free from odors. Interview with Executive Director states cleaning of resident rooms are scheduled and routine. Carpet cleaning is once a week and as needed.

Allegation #6 - Interview with Executive Director states that incontinence supplies are the responsibility of the residents or the resident's responsible party. Executive Director adds the they can assist obtaining incontinence supplies for resident, but are not required to provide these services or supplies.

Allegation #7 - Interview with Executive Director states that the facility is not required to provide residents with bedding and this is the responsibility of the residents or the resident's responsible party. Letter to new residents states what the resident's rooms are supplied with bed, microwave, and storage for utensils. Bedding is not listed in this letter.

Allegation #8- The facility is a 3 story, 2 winged facility. LPA toured facility lobby, outdoor lobby, dinning area, resident activities room, kitchen, library and hallways. LPA found these areas to be clean and free from odors. Interview with Executive Director states cleaning of resident rooms are scheduled and routine. Carpet cleaning is once a week and as needed.

Based on the information obtained there is not enough evidence to substantiate the aforementioned allegations. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. This report was signed by LPA Prieto and Executive Director Pacia and a copy was left with the facility.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:	DATE: 05/26/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2023

LIC9099 (FAS) - (06/04)

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