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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530072
Report Date: 12/16/2024
Date Signed: 12/16/2024 10:51:41 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
09/20/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240920114542
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: 6DATE:
12/16/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Maria Tess Hartwick-CaregiverTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff did not ensure that medication was inaccesible to residents
Staff did not maintain the required temperature in the facility refrigerator
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 Maria Tess Hartwick and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First allegation: Staff did not ensure that medication was inaccessible to residents. Regarding the allegation “Staff did not ensure that medication was inaccessible to residents” On 9/23/2024 LPA discovered by via photo images that facility was storing medication in a refrigerator that was not maintained locked and medication was accessible to residents in care, which can be a potential health, and safety concern to residents in care.

Second allegation: Staff did not maintain the required temperature in the facility refrigerator. Regarding the allegation” Staff did not maintain the required temperature in the facility refrigerator” During the review of records LPA discovered by via photo images that facility refrigerator temperature was set at 6C,
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
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 6
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
09/20/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240920114542

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: 6DATE:
12/16/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Maria Tess Hartwick-CaregiverTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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2
3
4
5
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7
8
9
Staff did not ensure that smoke alarms remain operable to conform with the regulations adopted by the State Fire Marshal
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 Maria Tess Hartwick and explained the purpose of the visit. The investigation consisted of interviews, and observations.

First allegation: Staff did not ensure that smoke alarms remain operable to conform with the regulations adopted by the State Fire Marshal. Regarding the allegation “Staff did not ensure that smoke alarms remain operable to conform with the regulations adopted by the State Fire Marshal” LPA conducted an inspection of all smoke alarm detectors and observed that all detectors along with carbon monoxide detectors were operable. Staff #1 informed LPA that smoke detector alarm was going off a few times, but the batteries were replaced and fixed the issue. Based on corroborating evidence obtained during the course of the investigation, LPA has determined that the above allegation is Unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 56-AS-20240920114542
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: 12/16/2024
NARRATIVE
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Unsubstantiated: meaning that 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.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Caregiver Maria Tess Hartwick at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 56-AS-20240920114542
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: 12/16/2024
NARRATIVE
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a temperature that can potentially be harmful. According to title 22 freezers shall be maintained at a temperature of 0 degrees F (-17.7 degrees C), and refrigerators shall maintain a maximum temperature of 40 degrees F (4 degrees C). 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, 87465 Incidental Medical and Dental Care, 87555 General Food Service Requirements 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 to Facility Caregiver Maria Tess Hartwick at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 56-AS-20240920114542
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: 12/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2025
Section Cited
CCR
87465(a)(2)
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Incidental Medical and Dental Care....
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
....(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidence by:
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licensee has agreed to read over the "Incidental Medical and Dental Care" regulation and provide training to all staff. Licensee will provide a copy of training signed and dated by all staff. Training will be emailed to LPA Guerrero by POC date 1/10/2025.
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Based on observation, and interviews, licensee did not ensure medications were kept locked and secure for 5 out of 5 residents, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type B
01/10/2025
Section Cited
CCR
87555
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General Food Service Requirements....
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.
This requirement is not met as evidence by:
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licensee has agreed to read over the "General Food Service Requirements" regulation and provide training to all staff. Licensee will provide a copy of training signed and dated by all staff. Training will be emailed to LPA Guerrero by POC date 1/10/2025.
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Based on observation, and interviews, licensee did not ensure refrigerator was kept at the temperature according to title 22, which poses an immediate Health, Safety, or Personal Rights risk 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: 12/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6