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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603750
Report Date: 06/05/2025
Date Signed: 06/06/2025 07:36:48 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/15/2022 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20220215101301
FACILITY NAME:VILLA LORENAFACILITY NUMBER:
374603750
ADMINISTRATOR:COLLADO JR, JOSEFACILITY TYPE:
740
ADDRESS:14740 VIA FIESTATELEPHONE:
(858) 756-9600
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY:85CENSUS: 63DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Nora Garza. TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff handled resident roughly resulting in bruises.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA was allowed entry by the receptionist and met with Administrator Nora Garza. LPA identified herself and discussed the purpose of the visit. Investigation was conducted by the Community Care Licensing (CCLD) Investigative Branch (IB) Investigator.

The Department’s investigation included a tour of the facility, observations, records reviews, and interviews with staff and outside sources. Prior to the investigation, the CDSS/CCLD/Investigations Branch Investigator interviewed the reporting party and reviewed the facility file.

On February 15, 2022, Community Care Licensing (CCL) received a complaint alleging facility staff handled resident roughly resulting in bruises. More specially, that an altercation occurred between Resident #1 (R1) and Staff #1 (S1) that resulted in bruising of R1.
(Continued on LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
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 6
Control Number 08-AS-20220215101301
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: VILLA LORENA
FACILITY NUMBER: 374603750
VISIT DATE: 06/05/2025
NARRATIVE
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(continued from 9099)
Page 2 of 3

Interviews reveal on 02/13/2022, S1 reportedly attempted to help Resident#2(R2) change their incontinence brief. Resident #1(R1) began to hit S1 in the back, while S1 was helping R2, and was reported to have attempted to put S1 in a choke hold while yelling at S1 to “leave [R2] alone”. S1 admittedly grabbed R1’s wrists to try to remove R1’s arm from around S1’s neck. When that did not work, S1 reported they began to strike at R1’s hand with a closed right fist until R1 let go and S1 could free themselves.

S1 reported the incident to Staff #2 (S2). The altercation resulted in bruising and skin tears of R1’s hands and wrists on both the right and left limbs. Staff interviews corroborated the details of the incident. When a staff member asked R1 what happened, R1 pointed to S1 and confirmed that they had caused the injury. Due to R1 diagnosis of dementia they could not provide any other statements about what happened.
R2 is also diagnosed with dementia and could not provide a statement about the incident.

S2 reported this incident to their supervisor, Staff #3 (S3), who also reported the incident to their supervisor, Staff #4 (S4). In addition to S1 causing bruising to R1, the Licensee did not report this incident to the licensing agency. [See LIC 811 Confidential Names List for a description of R1, R2 S1, S2, S3 and S4]

Staff interviews and resident family interviews reveal other incidents where S1 has been inappropriately rough with residents in care or verbally abusive with residents in care. Department Interview with the executive director reveal S1 is no longer working at the facility.

(continued on LIC 9099)

SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20220215101301
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VILLA LORENA
FACILITY NUMBER: 374603750
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2025
Section Cited
CCR
87468.2(a)(8)
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87468.2 (a)(8) Additional Personal Rights of Residents in Privately Operated Facilities (a)(8) In addition to rights listed in Section 87468.1, Residents shall have the following personal rights…to be free from physical abuse. This requirement was not met as evidenced by:
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S1, who was involved with incident was terminated by the facility.
The administrator agreed to attend and have memory care staff attend personal rights training regarding proper handling of residents who are comabtive as well as
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Based on interviews with staff and outside sources, records review, and photographs, Facility staff handled resident roughly resulting in bruises. Licensee did not comply with regulation for 1 of 69 residents. This caused an immediate health and safety risk to residents in care.
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proper protocol for residents who are being physically agressive with staff.

Proof of training is to be provided to Community Care Licensing by the POC date..
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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: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 08-AS-20220215101301
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: VILLA LORENA
FACILITY NUMBER: 374603750
VISIT DATE: 06/05/2025
NARRATIVE
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(continued from LIC9099-C)
Page 3 of 3

Based on S1’s own account of events, interviews with staff and outside sources, records review, and photographs evidence of bruising healing over time, a preponderance of evidence exists supporting that facility staff handled resident roughly, resulting in bruising. The allegation is, therefore, Substantiated. One (1) deficiency was cited per the California Code of Regulations, Title 22 (refer to the LIC 9099-D page). A Plan of Correction was jointly developed with the Licensee and the licensee staff.

An exit interview was conducted with Administrator Nora Garza, to whom a copy of this report, the LIC 9099-D page, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/15/2022 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20220215101301

FACILITY NAME:VILLA LORENAFACILITY NUMBER:
374603750
ADMINISTRATOR:COLLADO JR, JOSEFACILITY TYPE:
740
ADDRESS:14740 VIA FIESTATELEPHONE:
(858) 756-9600
CITY:SAN DIEGOSTATE: CAZIP CODE:
92127
CAPACITY:85CENSUS: 63DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Nora Garza. TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Licensee did not follow resident’s plan of care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above-mentioned allegation. LPA was allowed entry by the receptionist. LPA identified herself, met with, and disclosed the purpose of the visit to Administrator Nora Garza.

The Department’s investigation included a tour of the facility, observations, records reviews, and interviews with staff, residents, and outside sources. Prior to the investigation, LPA interviewed the reporting party and reviewed the facility file.

On February 15, 2022, Community Care Licensing (CCL) received a complaint alleged that the licensee did not follow the resident’s plan of care. More specifically, resident #1 (R1) did not receive standby assistance for showering for the months of June, July, and August in the year 2021. [See LIC 811 Confidential Names List for a description of R1], (Continued on 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20220215101301
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: VILLA LORENA
FACILITY NUMBER: 374603750
VISIT DATE: 06/05/2025
NARRATIVE
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(continued from 9099)

Records review reveal resident #1 (R1) moved into the facility on 06/02/2021. A review of records also reveal while R1’s assessment documented the need for stand-by assist for showing upon move-in, R1’s plan of care indicated that R1 was independent for showers and R1 only needed assistance with dressing and prompting. Dressing and prompting were described as assistance with selecting an outfit for the day, prompting to shower, and checking back later to see if the shower was taken. Staff interviews supported that R1 was not receiving stand-by assist but rather that R1 was receiving services as outlined in the care plan of dressing and prompting assistance. A service plan log for recording daily care by staff indicated that stand-by assist was indeed provided in the months of July and August through the period in time at which a reassessment was done on 08/26/2021. The department records review of daily logs initialed by staff show that stand-by assist was provided for July and August. Facility staff could not produce a service plan log for June as there was a change in staffing and records for June could not be located.

A review of R1's reassessment at the end of August 2021 deemed R1 independent for showering. Therefore, according to records stand-by assist was provided and was a higher level of care than indicated on the care plan. Records review showed that more care was provided not less than was outlined in the care plan. An interview was attempted with R1 but due to dementia diagnosis, no pertinent information was obtained. 

Due to facility staff being able to provide documentation of more care being provided to R1 than outlined in the care plan and due to contradicting evidence with interviews and records review, this allegation is found to be UNSUBSTANTIATED. 
 
An exit interview was conducted with Administrator Nora Garza. A hard copy of this report and Licensee's Rights (LIC 9058 03/22) were provided to the Administrator at the conclusion of the visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6