374603750-4-14-2026-08-AS-APAO-DTMR7W-20260430124701

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603750
Report Date: 04/14/2026
Date Signed: 04/14/2026 04:52:23 PM

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
12/04/2025 and conducted by Evaluator Arian Golbakhsh

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20251204154407

FACILITY NAME:	VILLA LORENA		FACILITY NUMBER:	374603750
ADMINISTRATOR:	GARZA, NORA		FACILITY TYPE:	740
ADDRESS:	14740 VIA FIESTA		TELEPHONE:	(858) 583-8480
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92127
CAPACITY:	85	CENSUS: 60	DATE:	04/14/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Business Office Director Denise Nguyen and Executive Director Nora Garza		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Licensee did not meet resident's incontinence needs.
Facility did not follow food service requirements.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced subsequent visit for a complaint investigation and delivered findings regarding the above mentioned allegations. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit to Business Office Director Denise Nguyen, then Executive Director Nora Garza, who arrived shortly after LPA.

On 12/04/2025, the Department received a complaint where it was alleged that the facility left a resident (identified as R1) in a soiled brief for an extended period of time. Additionally, it was alleged that the facility was not following food service requirements, specifically that the facility did not provide a full dinner meal to R1 and that food items in the fridge of R1's unit were not labelled. The Department’s investigation consisted of unannounced facility visits, records review, and interviews with staff, residents, and outside sources.

[Continued on LIC 9099-C 1/3]

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026

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 3

Control Number 08-AS-20251204154407

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: 04/14/2026

NARRATIVE

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[Continued from LIC 9099]

R1 was a resident at the facility residing in the Assisted Living (AL) unit of the facility before transitioning into the Memory Care (MC) unit. R1 did have a diagnosis of Mild Cognitive Impairment (MCI). R1 additionally had an assigned personal companion from an outside agency.

In regards to the allegation of having been left in a soiled brief for an extended period of time, per file review of R1's records, R1 was fully incontinent and required assistance with toileting. Per review of R1's assessment dated 10/27/25, R1 only needed stand-by assist for toileting. The complaint alleged that there were only two (2) caregivers scheduled that day and it was unknown how long R1's brief was soiled for. Per review of the staff schedule, there were only 2 caregivers assigned to the AL unit for the 2-10:30pm shift on that date.

Interviews with staff revealed that resident briefs are checked at least every two (2) hours, with one staff member specifying that they are changed earlier as needed. Multiple staff members interviewed recalled R1, with two (2) recalling that R1 utilized briefs for incontinence care. None of the staff interviewed shared any issues or concerns regarding R1's incontinence care. One staff member interviewed shared that though there may occasionally be shifts short staffed, staff do all they can to ensure residents needs are met timely and residents do not feel any negative effects of the lack of staff. Interview with an outside source responsible for R1's care shared no concerns regarding R1's care at the facility, including incontinence care. Interview with residents, R1 included, as well as other outside sources, did not reveal any concerns regarding staff attentiveness or care.

In regards to the additional allegation regarding the food service requirements, the complaint specified two concerns: 1) that the facility did not provide a full dinner meal to R1 on a specified date as a drink and dessert did was not given with the meal brought to R1's room, and 2) that fruit in R1's unit fridge did not have dates on them. As in-unit fridges are private for residents, there is no specific regulation requiring their contents to be dated.

[Continued on LIC 9099-C 2/3]

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20251204154407

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: 04/14/2026

NARRATIVE

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[Continued from LIC 9099-C]

Interviews with residents and outside sources revealed no concerns regarding food at the facility. Per staff interviews, R1 was often slow eater, and closer to transitioning to the MC unit, they would sometimes have tray service brought to their room for assistance with feeding. Per review of R1's assessment dated 10/27/25, R1 was independent for meals, aside from needing staff assistance with escort to meals. One staff member interviewed shared that staff, if given permission by residents, checked the unit fridges weekly to toss out any items that have gone bad. In regards to R1, it was shared that R1 didn't utilize their fridge and staff would sometimes store extra items that R1 didn't finish during a meal for the remainder of the day only, should R1 request it later.

Additionally, it was shared that in regards to tray service, if it was noted that an item was missing from the prepared meal, staff were to return back to bring it for the resident. Per one staff interview, R1 could be picky about sweets and staff would come to know R1's preferences for desserts and sometimes not add it to the tray depending on what it was that meal. One resident interview shared that residents can get snacks and desserts at anytime, and an interview with administrative staff corroborated this as well.

LPA additionally had toured through the main kitchen and inspected refrigerated, frozen, and dry storage food items. LPA noted no concerns during their inspection about the variety, freshness, and safe storage of items inspected.

Based on interviews and records review, while the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred – therefore the allegations have been determined to be UNSUBSTANTIATED. An exit interview was conducted with Executive Director Garza to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058) were provided. Their signature below confirms receipt of these documents.

SUPERVISORS NAME: Sabel Martinez
LICENSING EVALUATOR NAME: Arian Golbakhsh
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2026

LIC9099 (FAS) - (06/04)

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