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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603750
Report Date: 06/05/2025
Date Signed: 06/23/2025 01:23:02 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
02/10/2022 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20220210154600
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 COVID-19 guidance
Facility was in disrepair
Staff spoke inappropriately to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Nora Garza


OIn February 2022, Community Care Licensing (CCL) received complaints alleging that Licensee staff did not follow COVID-19 guidance, Resident #1(R1) room was in disrepair and licensee staff spoke inappropriately to R1. CCLD’s investigation involved unannounced facility tours, review of relevant records and written correspondence, and interviews with staff, residents and outside sources.

[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 7
Control Number 08-AS-20220210154600
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 B
06/05/2025
Section Cited
CCR
87303(a)
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87303 Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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Licensee staff will provide documentation of rehab inspections for unit 106 by POC date. LPA provide the mold report for unit #106 for reference..
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This requirement was not met as evidence in; Based on observations and interviews the licensee did not treat for mold in 1 of XX (GET CENSUS) persons in care which posed a potential Health and Safety 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: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20220210154600
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 B
07/03/2025
Section Cited
CCR
87468.2(a)(8)
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87468.2 – Additional Personal Rights...(a)(8) In addition… residents… shall… be free from... intimidation, and verbal, mental, physical, or sexual abuse
This requirement was not met as evidenced by:
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Administrator agreed to provide LPA with documentation of training for all for personal rights and provide documentation by POC date.
S1 was no longer works at the facily as of 9/27/2024.
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Based on records review and interviews,
S1 used language that was intimidating to (R1). This posed a potential personal rights and safety risk to 1 of xx residents in care.
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Type B
07/03/2025
Section Cited
CCR
87470(a)
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87470 Infection Control Requirements (a) A licensee shall ensure that infection control practices are maintained as follows: This requirement was not mer as evidenced by:
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Administrator agreed to provide LPA with documentation of training on infection control for all staff by POC date.
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Based on interviews, the licensee did not ensure staff followed COVID-19 guidance, which posed a potential Health, Safety, and Personal Rights risk to all 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: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
02/10/2022 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20220210154600

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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Staff did not meet resident's needs
Staff did not meet resident's incontinence needs
Staff retailiated against a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Nora Garza.

On February 2022, Community Care Licensing (CCL) received a complaint alleging that Licensee staff did not meet resident #1(R1) needs, licensee staff did not meet R1 incontinence needs and licensee staff retailiated against a R1. CCL’s investigation involved unannounced facility tours, review of relevant records and written correspondence, and interviews with staff, residents and outside sources.

[CONTINUED ON LIC 9099-C]
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20220210154600
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 LIC 9099-A)
It was alleged staff retaliated against a resident.  More specifically it was alleged  Staff #1 (S1) spoke of retaliating against resident #1 (R1) by stating they are trying to move R1 from the facility. Although the reported party stated they observed S1 speaking about retaliation. Staff interviews and interviews with residents did not corroborate the allegation, as staff consistently denied witnessing any form of retaliation by S1 to residents. Resident interviews, including R1, denied witnessing any form of retaliation by S1 to residents.

It was also alleged staff did not meet residents needs and staff did not meet resident's incontinence needs. More specially, licensee staff did not help with R1 for over an hour after R1 request with incontinent needs, clothing changing and providing breakfast service.  A review of R1 needs and service (dated 11/26/2021) reveals  toileting and grooming as independent. Additionally resident will remain as much independence as possible with bathing and showering.  The report further states the R1 will retain ability to partially dress self and staff will help with balance while dressing. R1 was interviewed around the time of the complaint and no evidence could be found in the interview to support the allegation. Records review as well as interviews with the licensee, staff, and medical personnel, were conducted and revealed that although some residents required more incontinence and toileting care, there wasn’t any documentation of concern for neglect, abuse, or non-accidental injuries were noted. 

Based on the Department's investigation, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is unsubstantiated. An exit interview was conducted with Administrator Nora Garza to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) will be provided at the conclusion of today's visit.
SUPERVISORS NAME: Denise Powell
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 05/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 08-AS-20220210154600
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)
(Pages 2 of 3)

According to records review R1's physician report reveals they can communicate and have no issues with confusion or depression. R1's needs and service plan (dated 1/14/2022) states they have stand-by assistance, with bathing, hair care and personal hygiene.

It was alleged that facility staff was not following COVID-19 protocol. More specifically, licensee management team kept positive COVID-19 cases from care giving staff, residents, and families of residents . Care giving staff and resident were interviewed around the time of the complaint and revealed that residents and staff  had tested positive for COVID-19 and stated that the facility did follow the COVID-19 protocol by not informing care staff or residents of positive COVID-19 cases. Records review revealed COVID-19 related incident reports were not submitted to CCL from 12-21-2020 to 2-8-2021.   Information gathered during staff and resident interviews indicated that staff facility-wide policy, supported by CCLD PIN recommendations, was to  communicated to families in writing, report infection disease outbreaks to CCL, and adhere to infection control personal protective equipment guidelines. Records review, staff interviews and resident interviews gave corroborating evidence that Licensee management staff did not follow CCL infection protocols.

It was further alleged staff spoke inappropriately to resident. More specifically Staff #1 (S1) yelled at R1 while standing outside their room entrance.   A written statement by R1 and resident #2(R2) reveal S1 used statements towards R1 that were hurtful.  R1 statement revealed when S1 discovered R1 had hired an outside agency to conduct mold testing, S1 approached R1 at their door (#106). S1 was angry and accused R1 of not reporting mold issues to maintenance. R1 then rebutted and tried to explain they reported the mold to maintenance  three (3) different times yet the mold was not removed only covered up.  R2 written statement revealed they witnessed R1 crying while S1 was yelling " this is my house and they (R1) have no rights here" Interview with current Administrator confirm S1 is no longer working at the facility.

(continued on LIC9099-C)

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

DATE: 05/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20220210154600
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)

It was further alleged the facility was in disrepair.  More specifically, R1's two living spaces within a two story building (room 106) had flood soaked walls and carpet, that was not addressed by facility and caused mold.  A written statement sent to CCL by R1 reveals they reported the flooding to the facility and the facility had not addressed the flooding for weeks. Musty odor was observed by residents and an independent mold inspection was performed on 1/2/2022 in room #106.  Inspection yielded high levels of mold and mold growth was present.   According to Outside Source #1(OS1) they witnessed the facilities director and executive director speaking of the  mold in room #106. According to the Centers for Disease Control, indoor mold has been proven to cause upper respiratory infections (www.cdc.gov). Therefore, the present mold is a health and safety concern for the clients in care.

Based on interviews, written correspondence record review and outside source reports the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The allegation is, therefore, Substantiated. Three (3) deficiencies were cited per the California Code of Regulations, Title 22 (refer to the LIC 9099-D pages). A Plan of Correction was jointly developed with the Licensee.An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator Nora Garza whose signature below confirms receipt of these rights.

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

DATE: 05/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/26/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7