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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 04:29:45 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
03/18/2022 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20220318124522
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 GarzaTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff falsified document
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an 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 and outside sources.

On March 18, 2022, Community Care Licensing (CCL) received a complaint alleging that the licensee's staff falsified documents. More specifically, a PRC COVID-19 test was altered for resident #1(R1). Interviews reveal that R1 developed symptoms of COVID 19 prior to an in-person visit by R1's responsible person on 2/12/2022. Interviews with R1's responsible person further reveal R1 was removed from isolation on 2/14/2022. The department conducted a records review for R1 and the charting records for R1 reflect a gap in chart reporting from 1/12/2022 to 3/25/2022. Therefore, the department could not confirm or deny the isolation time for R1
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 5
Control Number 08-AS-20220318124522
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)

Records review reveals a COVID-19 RT-PCR test was performed on 2/9/2022 for R1 by the facility staff.  The document provided by the licensee staff to R1 responsible person and to the ombudsman revealed the COVID-19 RT-PCR test was negative for R1.  However, the scan of the barcode reveals results for another person and the COVID-19 RT PCR test patience name on the document appears to be altered. 


The Department has investigated the above-mentioned allegation and based on record review and outside source interviews, the preponderance of the evidence has been met, therefore, this allegation is deemed substantiated. The following deficiency is cited per CA Code of Regulations, Title 22, and noted on the attached LIC9099-D page.

An exit interview was conducted with Administrator Nora Garza, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.
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 5
Control Number 08-AS-20220318124522
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
06/19/2025
Section Cited
CCR
87207
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False Claims.No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement.....the services provided by the facility. This requirement was not met as evidenced by:
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Adminsitrator will have staff review 87207 FALSE CLAIMS and provide signed doumentation that staff reviewed 87207. Licensee to provide documentation to CCL by POC date.
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Based on interviews and record reviews, The licensee staff faslified documents for COVID-19 results for R1. This posed a potential personal rights risk to all residents in 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: 06/05/2025
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 5
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
03/18/2022 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20220318124522

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):
1
2
3
4
5
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7
8
9
Staff did not notify authorized reprsentative of change of condition
INVESTIGATION FINDINGS:
1
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3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Amy Rodgers conducted an 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 and outside sources.

On March 18, 2022, Community Care Licensing (CCL) received a complaint alleging that staff did not notify authorized representative of a change of condition. More specifically, Resident #1(R1)'s reporting person was not notified R1 had cold like symptoms, a cough and a runny nose. Interviews with R1's responsible person revealed that R1 developed symptoms of COVID 19 prior to an in-person visit by R1's responsible person on 2/12/2022. Interviews with R1's responsible person further reveal R1 was removed from isolation on 2/14/2022. The department conducted a records review for R1 and the charting records for R1 reflect a gap in chart reporting from 1/12/2022 to 3/25/2022. Therefore, the department could not confirm or deny the is R1 was experiencing a change of condition. (continued on LIC9099-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: 4 of 5
Control Number 08-AS-20220318124522
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)

Due to facility staff not being able to provide documentation of additional 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: 5 of 5