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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 335530032
Report Date: 07/22/2025
Date Signed: 07/22/2025 01:54:41 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/12/2022 and conducted by Evaluator Raquel Hernandez
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220912172452
FACILITY NAME:VILLA DE ANZAFACILITY NUMBER:
335530032
ADMINISTRATOR:ESPINAL, KENNYFACILITY TYPE:
740
ADDRESS:5881 EL PALOMINO DRIVETELEPHONE:
(951) 683-3333
CITY:RIVERSIDESTATE: CAZIP CODE:
92509
CAPACITY:197CENSUS: 144DATE:
07/22/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Mark PaciaTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff are not providing adequate care to resident.
Facility phone(s) are not being answered.
Staff are not responding to Resident's Representative's requests for communication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Raquel Hernandez conducted an unnannounced visit for the purpose to deliver findings on the allegations listed above. LPA met with Administrator Mark Pacia and explained the purpose of the visit. The investigation consisted of staff interviews, resident interviews and facility tour.

For the allegation, Staff are not providing adequate care to resident.

LPA Hernandez conducted (8) resident interviews. 6 out of the 8 stated the facility staff do provide adequate care to residents in care. Additionally, LPA conducted (4) staff interviews. 4 out of the 4 staff indicated adequate care is being provided to residents in care.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
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 2
Control Number 56-AS-20220912172452
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLA DE ANZA
FACILITY NUMBER: 335530032
VISIT DATE: 07/22/2025
NARRATIVE
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For the allegation, Facility phone(s) are not being answered.

LPA Hernandez spoke with Staff #2 (S2) who indicated the facility phone does go to an automated system where residents are able to leave a voicemail if facility front desk is on another call. LPA conducted (8) resident interviews. 3 out of the 8 indicated they do not have any issues with the facility phone being answered. Additionally, 3 out of the 8 indicated they have not had to call the facility phone as they are given a pendant in the case they may need something.

For the allegation, Staff are not responding to Resident's Representative's requests for communication.

LPA Hernandez spoke with Staff #1 (S1) and Staff #3 (S3) who indicated all forms of communication are responded to in the event a resident's representative may call the facility. However, S3 indicated due to HIPAA laws, some information may require consent from resident or Power of Attorney documentation for financial or medical before facility releases any information. LPA conducted (8) resident interviews where 7 out of the 8 indicated resident's representative has no issues with contacting the facility or speaking with management.

Based on the evidence gathered during today’s investigation, the allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report (LIC9099) was discussed and provided to Administrator Mark Pacia.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Raquel Hernandez
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2025
LIC9099 (FAS) - (06/04)
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