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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 07:44:10 AM

Unsubstantiated


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
02/11/2022 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20220211100740
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 assist resident with medication administration
Resident was charged for items never provided
Licensee did not provide an itemized statement for charges
Licensee did not meet resident's transportation needs
Housekeeping services did not meet resident's needs
License did not meet resident's dining needs
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 

In February 2022, Community Care Licensing (CCL) received complaints alleging that Licensee staff did not assist a resident with medication administration, the resident was charged for items never provided, Licensee staff did not provide an itemized statement for charges, Licensee did not meet the resident's transportation needs, and License did not meet resident's dining needs.

CCLD’s investigation involved unannounced facility tours, review of relevant records and written correspondence, and interviews with staff, residents and outside sources.
(Contuned on LIC 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: 1 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
02/11/2022 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20220211100740

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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2
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Licensee did not respond to resident's communication requests
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. CCLD’s investigation involved unannounced facility tours, review of relevant records and written correspondence, and interviews with staff, residents and outside sources.

In February 2022, Community Care Licensing (CCL) received a complaint alleging that the Licensee staff did not respond to the resident's communication requests. More specifically, Licensee staff did not respond to requests for residents' financial information, services provided by the facility, and residents' medical information. Records review of written correspondence to CCL reveals that Resident #1(R1) and Resdient #(R2)'s responsible party requested documentation regarding the details of charges for their residency at the facility, and Licensee staff did not provide the documentation.

(continued on LIC9099)




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: 2 of 6
Control Number 08-AS-20220211100740
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 form LIC9099)

Further review of the written correspondence reveals that during a roundtable discussion with residents and the executive director, R1 specifically requested information from the executive director regarding the laundry service schedule. However, the executive director did not respond to inquiries regarding the laundry service during the roundtable discussion or give a personal response to R1.

Based on interviews with residence and records review and written statements to CLLD, a preponderance of evidence exists supporting that Licensee staff did not respond to resident's communication requests. 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.

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: 3 of 6
Control Number 08-AS-20220211100740
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
87468.1(a)(9)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents...shall have... the following personal rights:(9) To have communications to the licensee from their representatives answered promptly and appropriately.
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The administrator agrees to provide appropriate staff with customer service training regarding answering inquiries from resdience in a timely manner.
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This requirement was not met as evidence in; Based on interviews and records review the licensee did not communicate with residents promptly and appropriately in 3 of of XX persons in care which posed a potential Personal Rights risk to persons in care.
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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: 4 of 6
Control Number 08-AS-20220211100740
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)
Page 2 of 3

 It was alleged that the Licensee did not assist a resident with medication administration. More specifically,  Resident #2(R2)  wanted to smoke prescribed THC, and the facility refused to allow smoking on campus.  Records review reveals that R2 and  R2's responsible party were aware of the no-smoking policy before admission to the facility. A records review from the sales director's documentation confirmed that R2 was advised to seek other non-smoking methods of prescribed THC prior to moving to the facility..

It was further alleged that residents were charged for items never provided, and the Licensee did not provide an itemized statement for charges. More specifically, Resident #1(R1) financial advisor has not received an itemized bill for the non-medical charges paid to the facility by R1 account..  Written reports submitted by another Resident responsible party reveal the facility charged the resident services never provided.   Further information in the report states that after making a complaint to the facility regarding the services, the facility refunded the questionable charges without presenting an itemized statement.   Written reports by another family member reveal that some financial discrepancies were noted, including being charged for services not rendered. However, interviews and records could not provide additional evidence to support the allegation.

It was further alleged that the Licensee did not meet the resident's transportation needs. More specifically, Resident #1 (R1) was promised open-ended transportation services provided by the facility.  Review of records, more specially the Villa Lorena Flyer- Services and Amenities state: Utilities: Weekly housekeeping and laundry services, maintenance, utilities, basic cable and internet, on staff driver up to 10 miles are all included in rent. A records review of an email from the sales office to a prospective resident as well as a folded advertised flyer state: Monday-Sunday transportation is available (Shopping days every Monday and doctor's appointments on Tuesday through Thursday). A review of records as well as the licensee printed material reveals that the Licensee does not provide open-ended transportation.

(continued on LIC9099-C)
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: 5 of 6
Control Number 08-AS-20220211100740
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 that the Licensee's housekeeping services did not meet the resident's needs, and the Licensee did not meet the resident's dining needs. More specifically, R1 reports they have no idea who is in charge of doing their laundry or how it is to be collected or returned. R1 also reports that there is an increasing amount of prepackaged, pre-prepared food being served. A review of records reveals housekeeping was scheduled for service every Tuesday for R1. The menu collected by the department during the time of the allegations was reviewed, and it included a variety of choices, such as poultry, beef, seafood, salads, sandwiches, and other balanced, healthy options.

Based on the Department's investigation, there is not a preponderance of evidence to prove the alleged violations occurred. Therefore, the allegation are 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: 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