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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603750
Report Date: 06/05/2025
Date Signed: 06/05/2025 04:18:20 PM

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
03/25/2022 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20220325123701
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 did not provide records to resident's responsible party
Facility did not notify resident’s responsible party of an incident
Facility did not update resident's records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted a 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.

On March 25, 2022, Community Care Licensing (CCL) received a complaint alleging that the facility did not provide records to the resident's responsible party, did not notify the resident’s responsible party of an incident, and did not update the resident's records.

During the investigation, the department collected resident records, conducted interviews, and reviewed written correspondence. Based on Resident 1 (R1) Physician’s Report dated April 22, 2022, R1 is diagnosed with Alzheimer's Dementia, and R1 has a designated responsible party. Additionally, R1’s Preplacement Appraisal reveals R1 needs assistance with all dressing and prompting.
(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: 1 of 4
Control Number 08-AS-20220325123701
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)
It is alleged that the Licensee did not provide records to R1's responsible party upon request.  Records reviews of written correspondence reveal that R1's responsible party requested R1's medical records, including a wound care document and progress notes, after an incident involving R1 on 2/13/2022.  R1's responsible party further reports that after they verbally requested the records, two emails were sent, a few weeks apart,  to the executive director requesting copies of R1's records. On 3/18/2022, the executive director provided some documents, but not the requested documents.  It was further reported that R1's responsible party contacted the executive director by phone, and they denied having any wound care notes or progress notes for R1.

I was also alleged that the Licensee staff did not notify the resident’s responsible party of an incident.  The department interviews with staff revealed that R1 was involved in an incident on 2/13/2022 that caused injury to their arms and hands. After the incident, the condition of R1 was not communicated in writing to R1 responsible person.   Based on a review of records and multiple interviews with staff, there was sufficient information to determine a written report was not submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence.

It was also alleged that the licensee staff did not update R1 records to reflect the incident on 2/13/2022.  A review of written correspondence dated 3/24/2022 reveals that R1's reporting person requested a file review and was physically shown a file that did not contain documentation for R1's incident on 2/13/2022 or any other relevant documentation. The department requested records for R1 on 2/15/2022 and did not receive records of illness, injury, medical or dental care, or information on R1's function or needs.

Based on interviews with staff, records review and written statements to CLL, a preponderance of evidence exists supporting that Licensee staff did not provide records to resident's responsible person, did not notify resident’s responsible person of an incident, and did not update resident's records. 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 and their staff..

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

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20220325123701
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
87468.2(a)(19)
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87468.2(a) In addition to the rights listed in Section 87468.1…personal rights:(19)To have prompt access to review all of their records…2 business days..This requirement was not met as evidenced by:
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LPA had a roundtable discussion with the LIcensee and thier Administration staff on 6/5/2025,regarding regulation 87468.2(a)(19), The licensee and staff agreed they understand the regualtion.
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Based on records review and interviews, the licensee did not provide prompt access to review records in 1 of 63 persons in care, which posed a potential Personal Rights risk to persons in care.
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Type B
07/03/2025
Section Cited
CCR
87211(a)(1)
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Reporting Requirements.(a) Each licensee... reports as the Department may require...(1) A written report shall be submitted to the licensing agency and to the person responsible... within seven days of the occurrence..

This requirement was not met as evidenced by:
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The Adminsitror agrees to provide appropriate staff with training on mandated reporting requirements. Proof of training is to be provided to Community Care Licensing by the POC date.
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This requirement is not met as evidenced by: Based on record review and interviews, the licensee did not ensure an incident report was completed forX out of X residents [R1], which poses a potential health and safety risk to residents 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: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20220325123701
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
08/05/2025
Section Cited
CCR
87506(b)(13)
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Resident records.(b) Each resident’s record .... information:(13)Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services.
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The Licensee and the resident service director agreed to review all 63 files to ensure files contain regualtion 87506(b)(13) information.
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Based on records review and interviews, the licensee did not update records in 1 of 63 persons in care, which posed a potential Personal Rights risk to persons in care.
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The resident service director also agreed to re-train med techs to ensure that accurate and timely charting is completed. 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: 06/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4