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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530072
Report Date: 11/22/2024
Date Signed: 11/22/2024 11:37:49 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
09/06/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240906161537
FACILITY NAME:VILLA DESCANSO DE AMORFACILITY NUMBER:
365530072
ADMINISTRATOR:THOMPSON, GABRIELAFACILITY TYPE:
740
ADDRESS:15453 ELM LANETELEPHONE:
(909) 393-6201
CITY:CHINO HILLSSTATE: CAZIP CODE:
91709
CAPACITY:6CENSUS: 5DATE:
11/22/2024
UNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Asenath Lainez-MunozTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff did not allow the resident to leave the facility.
Staff did not release the resident's medication.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Caregiver Asenath Lainez-Munoz and explained the purpose of the visit. The investigation consisted of interviews and review of records.

First allegation, Staff did not allow the resident to leave the facility. Regarding the allegation “Staff did not allow resident to leave the facility” LPA conducted interviews with facility Administrator and responsible party, throughout interviews, interviews revealed that Resident#1 Responsible Party informed Facility Administrator regarding Resident #1 moving out of the facility. However, it was reported that Resident #1 Responsible Party did not provide a formal 30-day discharge notice to the Administrator. On 8/22/2024 Resident#1 was prevented from being discharged from the facility. Administrator indicated that responsible party was trying take Resident#1 without paying the facility for care services. Resident was held at the facility for approximately 45-minutes.

Second Allegation, Staff did not release the resident’s medication.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
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-20240906161537
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VILLA DESCANSO DE AMOR
FACILITY NUMBER: 365530072
VISIT DATE: 11/22/2024
NARRATIVE
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Regarding the allegation “Staff did not release the resident’s medication” During interviews it was revealed that Resident#1 was to be discharged from the facility. On 8/22/2024, Resident#1 medication, was not released and provided to R#1 Responsible Party. Based on the evidence gathered during the investigation, the above allegations are Substantiated.


Substantiated: A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, 87468.1 (a)(3)(6)(18) Personal Rights of Residents in All Facilities, from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights, to Facility Caregiver Asenath Lainez-Munoz.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20240906161537
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VILLA DESCANSO DE AMOR
FACILITY NUMBER: 365530072
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/20/2024
Section Cited
CCR
87468.1(a)(6)(18)
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87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. (18) To move from the facility.
This requirement is not met as evidence by:
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Administrator has agreed to read over Personal Rights of Resident in All Facilities 87468.1(a)(6)(18) regulation and will provide training to all staff. Administrator will provide a copy of the training to LPA. The training will provide signatures and acknowledgement by all staff. Plan of Correction will be emailed to LPA on POC date: 12/20/2024.
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Based on interviews, the Administrator did not follow Personal Rights of Resident and prevented R#1 to leave from the facility, which poses an immediate Health, Safety, or Personal Rights risks to persons in care.
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Type B
12/20/2024
Section Cited
CCR
87468.1(a)(3)
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87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.
This requirement is not met as evidence by:
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Administrator has agreed to read over Personal Rights of Resident in All Facilities 87468.1(a)(3) regulation and will provide training to all staff. Administrator will provide a copy of the training to LPA. The training will provide signatures and acknowledgement by all staff. Plan of Correction will be emailed to LPA on POC date: 12/20/2024.
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Based on interviews, the Administrator did not follow Personal Rights of Resident and did not release R#1 medication to R#1 Responsible Party, which poses an immediate Health, Safety, or Personal Rights risks to persons in care.
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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: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3