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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603825
Report Date: 04/26/2025
Date Signed: 04/26/2025 10:03:18 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/15/2024 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 18-AS-20241015113100
FACILITY NAME:KELLY'S FOOTHILL VILLAFACILITY NUMBER:
374603825
ADMINISTRATOR:KELLY WELKERFACILITY TYPE:
740
ADDRESS:1152 SAL LANETELEPHONE:
(760) 295-3523
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:6CENSUS: 6DATE:
04/26/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:ADMINISTRATOR KELLY WELKERTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility refusing to allow Resident additional care
INVESTIGATION FINDINGS:
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On 04/26/2025 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Kelly’s Foothill Villa and was greeted by Staff Clara Bactad (S1). LPA Calderon spoke to S1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the finding pertaining to the above-mentioned allegation.

The investigation consisted of the following: LPA Calderon interviewed Staff S1-S2, resident R1-R6. LPA Calderon obtained the following records: Admission agreement (dated 05/20/2024), physician report (dated 06/07/2024), incident report (dated 09/18/2024), Takara Hospice skilled nursing notes (dated 02/18/2025), Takara Hospice visit notes (10/15/2024 to 01/17/2025) for R1.

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20241015113100
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KELLY'S FOOTHILL VILLA
FACILITY NUMBER: 374603825
VISIT DATE: 04/26/2025
NARRATIVE
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Regarding the Allegation: Facility refusing to allow resident additional care.

This complaint alleged that the facility did not allow R1 hospice care. Records review indicate the following: Physician report indicate R1 nonverbal and has health issues. Incident report indicates that resident had a fall and hospice nurse was called. Admission agreement indicates that resident moved into the facility on 05/20/2024. Takara hospice visit notes indicate that resident was given hospice services from 10/15/2024 to 01/17/2025. Takara Hospice nursing notes indicates that resident passed away on 01/18/2025. Interviews indicate the following: 2 out of 2 staff deny the allegation. R1-R6 could not answer any questions due to health issues and was non-verbal.

Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “facility refusing to allow resident additional care” is found to be UNSUBSTANTIATED.

No deficiencies cited during today's visit.



An exit interview was conducted, and a copy of the Complaint Report were provided to the Staff Clara Bactad (S1).
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2