Garden Grove Villa

Type of visit: Case Management - Other

On 06/10/2026, Licensing Program Analyst (LPA) conducted an unannounced Case Management visit to the facility to amend documentation associated with a complaint investigation control # 31-AS-20251205084314, conducted on 12/09/2025. Upon arrival, LPA met with the staff and the Administrator was contacted and the Administrator arrived shortly after. LPA explained the purpose of the visit. LPA reviewed the appeal determination issued by the Regional Manager in response to the licensee's appeal dated 12/24/2025 regarding deficiencies cited during the complaint investigation conducted on 12/09/2025. During today's visit, LPA provided the facility with amended deficiency page to reflect the appeal determination. As a result of the appeal review, the deficiency cited under California Code of Regulations, Title 22, Section 87211(a)(1)(D), Reporting Requirements, was dismissed and amended to Section 87211(a)(2), Reporting Requirements. The deficiency cited under Section 87464(f)(1), Basic Services, remains in effect as originally issued. No new deficiencies were cited during today's Case Management visit. An exit interview was conducted, and copies of this report and the amended complaint documentation were provided to the Administrator.the state’s words, verbatim · CDSS document, Jun 10, 2026

Type of visit: Office

Licensing Program Manager (LPM) Nichelle Gillyard, Licensing Program Manager (LPM) Mary Flores, and Licensing Program Analyst (LPA) Huma Rahimi met with the Administrator Neil Morales, to conduct an Informal Conference held at the Woodland Hills South Adult and Senior Care Regional Office. The purpose of the informal was to discuss the history of elopements which resulted in deficiencies. LPM made introductions and verified the current administrator information, facility land line phone number, cellular phone number, liability insurance, and facility’s e-mail. LPM reviewed and discussed LIC500 Personnel report and staffing. The current census is 6. On December 5, 2025, the department received a complaint with two (2) allegations. December 9, 2025, LPA Rahimi, conducted the complaint investigation and substantiated the complaint which resulted in an elopement. Staff did not provide adequate supervision to a resident. Staff did not follow proper reporting requirements. The following deficiencies were issued: 1. Basic Services 2. Reporting Requirements Continue on LIC 809C On August 21, 2025, LPA conducted a case management visit for a resident elopement on 08/14/2025. The following deficiencies were issue: 1. Care of Persons with Dementia 2. Resident Records Moreover, on May 17, 2019, a case management visit was conducted for elopement of a resident on 05/13/2019. The following deficiency was issued. 1. Basic Services LPM discussed recently submitted appeal on December 24, 2025. During the meeting LPM discussed the Technical Support Program (TSP) with the Administrator to which Administrator stated that it will not be necessary. Other: LPM discussed the reporting requirement, and civil penalties were discussed. LPM discussed the administrative process. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Jan 16, 2026

Allegation investigated: Staff did not provide adequate supervision to a resident. Staff did not follow proper reporting requirements.

This is an amendment to the original report issued on 12/09/2025 to correct the deficiency cited under Section 87211(a)(1)(D) to Section 87211(a)(2), Reporting Requirements. At 9:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannouced initial complaint visit to investigate the above stated allegations. LPA met with the Staff #1 (S1) Dell Morales AKA Delinia Morales and the Administrator was contacted via telephone. LPA explained the reason for the visit. The Administrator arrived at the facility at 10:20 AM. During course of the investigation, interviews and record review were made. At 9:55, LPA requested resident and staff roster. At 10:05 AM, LPA requested copies of pertinent information which include, but not limited to Physician Report, Admission Agreement, Appraisal Needs and Services Plan and ect., relevant to the course of investigation. At approximately 10:15 AM, LPA conducted a physical plant tour. Between 10:20 AM to 1:15 PM LPA conducted an interview with the Administrator, two staff members, and four (4) out of six (6) residents who were avaliable at the facility. Continue on LIC 9099C Substantiated Staff did not provide adequate supervision to a resident. The allegation stated that Resident #1 (R1) was found wandering outside the facility. It was also reported that R1 was unable to recall the address or phone number of the facility and is very hard of hearing. To investigate this allegation, LPA conducted interviews with the Administrator, Staff #1 (S1), and Staff #2 (S2). LPA was informed that R1 routinely left the facility without staff supervision. Additionally, staff acknowledged that they had previously allowed R1 to leave the facility unassisted, despite R1 having mild cognitive impairment and hearing loss. S2 also stated that they did not check on R1 after he/she left the facility. The Administrator confirmed that R1 often left the facility without supervision and that staff did not check on R1 because he/she would return later. LPA reviewed R1’s physician report and observed that, while R1 has some ability to leave the facility unassisted, the physician included precautions and conditions—such as carrying a phone and being familiar with the area—to ensure safety. Additionally, interviews were conducted with four out of six available residents, one of whom reported observing R1 leaving the facility unassisted. During today's visit, LPA observed that two additional residents (R5 and R6), who are not permitted to leave the facility unassisted per physician orders, were found outside the facility without supervision and without the Administrator’s knowledge. R6 was out of the facility for approximately five hours (8:30 AM – 2:00 PM), and no report was made regarding the absence. Therefore, based on interviews, record reviews, and LPA's observation this allegation is Substantiated. Staff did not follow proper reporting requirements. It was alleged that the facility was not aware of R1 being out of the facility since 12/01/2025 at 4:00 PM and that no missing person report was made. To investigate this allegation, LPA conducted interviews with the Administrator, two (2) staff members, and residents; and reviewed facility records, physician reports, the incident report submitted to the Community Care Licensing Division (CCLD) on 12/03/25. Interviews revealed that R1 left the facility on 12/01/2025 at approximately 4:00 PM to do his personal laundry; however, the facility did not become aware of R1’s whereabouts until a hospital contacted the facility between 9:00–10:00 AM on 12/02/2025. The Administrator further acknowledged that no missing person report was filed with local law enforcement, despite R1’s mild cognitive impairment. Continue on LIC 9099C Additionally, during today’s visit, LPA observed that R5 and R6—both of whom have physician orders indicating they cannot leave the facility unassisted—were not present in the facility. The Administrator was unable to provide the location or schedule for R5’s day program. Furthermore, R6 left the facility at 8:30 AM to “find a lawyer” and did not return until 2:00 PM, and no missing person report was filed for R6. Based on interviews, observations, and record review, this allegation is SUBSTANTIATED. Deficiencies issued and appeal rights explained. Exit interview conducted and this report signed and delivered.the state’s words, verbatim · CDSS document, Dec 9, 2025 · control 31-AS-20251205084314

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Dec 16, 2025

87211(a) Each licensee shall furnish to the licensing agency... the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents..., shall be reported within 24 hours ... This requirement was not met as evidenced by: Based on interviews, observations, and record review, the licensee did not comply, by failing to notify the Department within 24 hours of an incident involving Resident #1 on 12/01/2025. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Administrator shall retrain all staff on 87211(a)(2) Reporting requirements for unusual incidents, including missing residents.Administrator shall implement a written procedure for immediate reporting of any resident absence or unusual incident. Proof of staff training and a copy of the updated reporting procedure shall be submitted to LPA by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 11, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). Based on interviews, observation and record review the licensee did not comply with the section cited by allowing residents with mild cognitive impairment and hearing loss were permitted to leave without supervision, contrary to physician precautions.the state’s words, verbatim · CDSS document, Dec 9, 2025

Plan of correction: Administrator to conduct training on supervision requirements, provide documentation of staff retraining, and implement a check-out/check-in system. A proof of training to be submitted to LPA by the POC due date (12/11/2025). Two residents who were not permitted to leave unassisted were still able to leave without staff awareness.

Type of visit: Required - 1 Year

At 9:50 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual inspection. LPA met with the staff Dell Morales AKA Delinia Morales and the the Administrator was contacted via telephone. LPA explained the reason for the visit. Administrator arrived at the facility shortly after. LPA and Administrator toured the facility inside and out. The facility is a single story building with seven (7) bedrooms, four (4) bathrooms, kitchen, dining room, office, garage, storage areas, common areas, and outdoor areas. It has an approved fire clearance for six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility serves residents with dementia. Hospice waivers approved for two (2) residents. Kitchen: At 10:00 AM, LPA observed that the kitchen contained a freezer, a refrigerator, and two pantries. LPA observed an adequate supply of perishable and non-perishable food. Sharp objects were locked near the stove. Cleaning solutions were locked in a cabinet next to the kitchen. Medications: Medications were locked near the kitchen in a cabinet and inaccessible to residents in care. Bedrooms: The facility has seven (7) private bedrooms. One (1) bedroom is designated as a staff room. All bedrooms contained a chair, nightstand, lamp, storage, and bed with clean and appropriate bedding. LPA observed that a resident in room #5 requires incontinence care and a staff approached to change the resident; however, the resident denied to be changed. The Administrator informed LPA that an incident report for the refusal will be submitted to Community Care Licensing Division (CCLD) accordingly. Continue on LIC 809C Bathrooms: The facility has four (4) bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 10:15 AM, LPA measured the water temperature in the shared bathroom to be 117.5 degrees Fahrenheit. Garage: The garage was locked from the outside. It contained a washer, dryer, paper supplies, extra water bottles, and detergents. Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 10:20 AM. LPA measured the living room temperature to be 75 degrees Fahrenheit. Extra linens were kept in a storage closet in the hallway between bedroom #1 and bedroom #6. Safety: At 10:30 AM, LPA observed a fully charged fire extinguisher in the kitchen and was purchased on 12/19/2024. In the backyard of the facility LPA observed personal belongings of a resident who exited the facility as of 05/22/2025. The Administrator is safeguarding the personal belongings of the former resident until he/she comes back from their vacation to remove the items. Administrator agreed to submit a plan to LPA of how to securely safeguard the personal belongings of the former resident. All emergency exit paths were free from obstructions. Exit gates were unlocked. At 10:35 AM, LPA tested four (4) out of four (4) smoke detectors to be operational. Smoke detectors were hard wired. LPA tested the carbon monoxide detector to be operational. LPA heard four (4) out of four (4) auditory alarms on and functioning during visit. Between 12:10 PM to 1:15 PM, LPA reviewed records of four (4) residents and two (2) staff. Residents and staff records appeared to be complete and updated. Administrative: LPA collected Certificate of Liability Insurance, and LIC500. No deficiencies issued during today’s visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jun 12, 2025

Allegation investigated: Resident was severely dehydrated and malnurished while under care. Staff do not ensure adaquet care and supervision is provided to resident.

Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced subsequent visit to this facility to deliver the final report. LPA met with Staff Dellnia Morales and the Administrator Neil Morales was contacted via telephone. LPA explained the reason for the visit. Administrator arrived at the facility at 2:50 PM. On 05/23/2024, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding allegations, “Resident was severely dehydrated and malnourished while under care, and staff do not ensure adequate care and supervision is provided to resident” The complaint was referred to Community Care Licensing Division’s Investigations Branch. The complaint was assigned to investigator Douglas Real. On 05/24/2024 LPA Rahimi conducted an initial 24-hour complaint visit. At 09:45 AM, LPA requested resident and staff roster. At approximately 09:55 AM, LPA conducted a physical plant tour. At 10:10 AM, LPA requested copies of pertinent information which include, but not limited to Physician’s report, Admission Agreement, Appraisal Needs and Services Plan. Continue on LIC 9099C Unsubstantiated Investigator Douglas Real conducted interviews with witnesses on 05/24/2024, Resident #1 (R1) family members on 08/06/2024, 08/26/2024, Administrator and facility staff on 06/20/2024, 07/02/2024, facility residents on 06/20/2024, and Hospital Medical Record was requested on 05/24/2024 and received on 06/05/2024. Allegation: Resident was severely dehydrated and malnourished while under care. The investigation findings revealed that R1 had been living at this facility since July, 2021 and was diagnosed with dementia and other health related issues. It was alleged that Resident #1 (R1) was hospitalized due to severe dehydration and malnutrition. Investigator conducted interview with the Administrator, and it was revealed that prior to the hospitalization, R1 became more confused than normal, and his/her food and water intake declined. Moreover, the facility staff was spending more time to encourage R1 to eat and drink. Additional interviews were conducted with three (3) staff members who also confirmed the above information. The facility staff notified R1’s responsible party and agreed to take R1 to the hospital for further evaluation. Interview with the POA of R1 also confirmed the information provided by both the Administrator and staff, and informed the investigator that the facility never withheld any food/water from R1. Furthermore, interviews with three (3) residents revealed that facility staff always provides enough food and water to all residents and never withheld any food or water. The investigator also reviewed Medical Records of R1 and did not observe any indication of malnutrition. Therefore, based on the information through interviews and review of hospital records that IB obtained, the above allegation is deemed Unsubstantiated at this time. Allegation: Staff do not ensure adequate care and supervision is provided to resident. It was alleged that the facility staff did not provide adequate care and supervision to R1 and found R1 without a diaper in his/her room. Investigator conducted an interview with the Power of Attorney (POA), and it was revealed that the facility always provided a good care to R1. The POA also informed the Investigator that the facility always keep in touch about any changes with R1’s condition in a timely manner. Furthermore, during the interview it was revealed that prior to R1’s hospitalization the facility staff found R1 without his/her diaper and informed the POA immediately. Facility staff provided a picture of R1 to inform the POA about R1’s condition. Subsequently, the POA shared the picture with another family member of R1 to inform them of R1’s condition. The other family member became upset and felt that R1’s situation was due to neglect and care. During the interview with the other family member of R1, the Investigator was informed that he/she visited R1 at the facility on weekly basis, and during all the visits he/she did not observe any neglect or abuse from the facility staff. Continue on LIC 9099C The other family member visited R1 on 05/12/2024 at the facility, and R1 did not report any lack of care and abuse from the facility staff. Interviews with the Administrator and staff also denied the allegation. Moreover, residents interviewed also did not have any concerns regarding the lack of care and supervision. Based on the investigator interviews this allegation is deemed Unsubstantiated at this time. No deficiency cited. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Mar 14, 2025 · control 31-AS-20240523141037

Type of visit: Case Management - Incident

At 12:45 PM, on 08/21/2024, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced case management visit to this facility. LPA met with the staff who granted access to the facility. The Administrator was contacted and LPA disclosed the reason for the visit. Administrator arrived at the facility shortly after. The Administrator had to leave and designated the staff to sign today's report on their behalf. Today’s case management visit is to follow up on an incident previously reported on 08/15/2024, stating that R1 left the facility unassisted on 08/14/2024, at around 4:00 AM. LPA conducted an interview with the Administrator and LPA was informed that the Los Angeles Police Department/911 was notified on 08/15/2024, at 10:27AM, and reported missing person. However, when the police came Administrator informed the police that R1 was previously served with an eviction notice on 07/28/2024. The Regional Office did receive an eviction letter on 07/31/2024, but it was determined unlawful because the Administrative did not provide supportive documents. Review of R1's physician's report date on 05/26/2021, revealed that R1 was diagnosed with dementia and was not able to leave the facility unassisted. In addition, Administrator failed to obtain a new physician's report for R1 for the past three years. Based on the interview and file review of R1 deficiencies will be cited on LIC 809D. Appeal rights explained. Exit interview conducted. Copy of report provided.the state’s words, verbatim · CDSS document, Aug 21, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(5)(A) · Plan of correction due date: Aug 28, 2024

Care of Persons with Dementia (5) Each resident with dementia shall have an annual...... as specified in Section 87458, Medical Assessment,,,,,, care needs. (A) ...., changes shall be made in the care and supervision provided......... This requirement was not met as evidenced by: Based on interviews & record review, the licensee did not ensure that the staff redirected or followed R1 when he left the facility unsupervised which poses a potential health & safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 21, 2024

Plan of correction: Administrator will conduct an in service training with all staff and will submit statement of understanding regardng this seciton.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Aug 28, 2024

87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. Resident records were incomplete and or missing signatures, which poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 21, 2024

Plan of correction: Administrator agreed to complete and update all four out of four residents records by the POC date.

Type of visit: Required - 1 Year

At 10:00 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual inspection. LPA met with the staff and Administrator contacted and LPA explained the reason for the visit. Administrator arrived at the facility shortly after. LPA and Administrator toured the facility inside and out. The facility is a single story building with seven (7) bedrooms, four (4) bathrooms, kitchen, dining room, office, garage, storage areas, common areas, and outdoor areas. It has an approved fire clearance for six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility serves residents with dementia. Hospice waivers approved for two (2) residents. Kitchen: At 10:15, LPA observed that the kitchen contained a freezer, a refrigerator, and two pantries. LPA observed an adequate supply of perishable and non-perishable food. Sharp objects were locked near the stove. Cleaning solutions were locked in a cabinet next to the kitchen. Medications: Medications were locked near the kitchen in a cabinet. However, LPA observed a full box with seven full bottles of Hair, Skin, and Nail 5,000 mg supplement in bedroom # six (6) in the closet accessible to residents in care. Additionally, LPA observed empty bottles of wine in room # six (6) in the closet. Bedrooms: The facility has seven (7) private bedrooms. One (1) bedroom is designated as a staff room. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. Bedroom # three (3) and bedroom # five (5) furnishings were clean, odorless, and in good condition. However, Bedroom # one (1), room # six (6), and room # four (4) furnishings and surroundings were not sanitary and clean. In bedroom # six (6), LPA also observed Lysol disinfectant spray bottle almost full accessible to resident in care. Continue on LIC 809C Bathrooms: The facility has four (4) bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 10:31 AM, LPA measured the water temperature in the shared bathroom to be 117.5 degrees Fahrenheit. Garage: The garage was locked from the outside. It contained a washer, dryer, paper supplies, extra water bottles, and detergents. Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 10:35 A.M. LPA measured the living room temperature to be 76 degrees Fahrenheit. Seating was arranged in the living room to accommodate physical distancing. Extra linens were kept in a storage closet between the kitchen and the staff room. Safety: At 10:45 AM, LPA observed a fully charged fire extinguisher in the kitchen and was purchased on 10/10/2023. All emergency exit paths were free from obstructions. Exit gates were unlocked. At 10:50 AM, . LPA tested four (4) out of four (4) smoke detectors to be operational. Smoke detectors were hard wired. LPA tested the carbon monoxide detector to be operational. LPA heard four (4) out of four (4) auditory alarms on and functioning during visit. Outdoor areas: At approximately 11:00 AM, LPA observed staff maintaining the front yard. All outdoor areas were free from debris. A locked shed was located in the back yard. All furniture was clean and in good repair. Between 12:10 PM to 1:30 PM, LPA reviewed records of five (5) residents and three (3) staff. Residents and staff records appeared to be complete and updated. Administrative: LPA collected Certificate of Liability Insurance, and LIC500. Deficiencies cited during today’s visit. Appeal rights explained. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Jun 12, 2024

Type of visit: Required - 1 Year

At 10:30 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual inspection. LPA met with staff and later Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out. The facility is a single story building with seven (7) bedrooms, four (4) bathrooms, kitchen, dining room, office, garage, storage areas, common areas, and outdoor areas. It has an approved fire clearance for six (6) non-ambulatory residents, of which one (1) may be bedridden. The facility serves residents with dementia. Hospice waivers approved for two (2) residents. Bedrooms: The facility has seven (7) private bedrooms. One (1) bedroom is designated as a staff room. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean, odorless, and in good condition. Bathrooms: The facility has four (4) bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 11:11 AM, LPA measured the water temperature in the shared bathroom to be 119.5 degrees Fahrenheit. Kitchen: The kitchen contained a freezer, a refrigerator, and two pantries. LPA observed an adequate supply of perishable and non-perishable food. Sharp objects were locked near the stove. Cleaning solutions were locked in a cabinet next to the kitchen. Medications were locked near the kitchen in a cabinet. Garage: The garage was locked from the outside. It contained a washer, dryer, paper supplies, extra water bottles, and detergents. Continue on LIC 809C Common Areas: Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 11:35 A.M. LPA measured the living room temperature to be 72.8 degrees Fahrenheit. Seating was arranged in the living room to accommodate physical distancing. Extra linens were kept in a storage closet between the kitchen and the staff room. Safety: At 11:45 AM, LPA observed a fully charged fire extinguisher in the kitchen and was purchased on 10/10/2023. All emergency exit paths were free from obstructions. Exit gates were unlocked. At 11:50 AM, . LPA tested four (4) out of four (4) smoke detectors to be operational. Smoke detectors were hard wired. LPA tested the carbon monoxide detector to be operational. LPA heard four (4) out of four (4) auditory alarms on and functioning during visit. Outdoor areas: At approximately 12:15 PM, LPA observed staff maintaining the front yard. All outdoor areas were free from debris. A locked shed was located in the back yard. All furniture was clean and in good repair. Between 12:30 PM to 2:00 PM, LPA reviewed records of six (6) residents and four (4) staff. Residents and staff records appeared to be complete and updated. Administrative: LPA collected Certificate of Liability Insurance, and LIC500. No deficiency cited during today’s visit. Exit interview conducted and copy of this report signed and delivered.the state’s words, verbatim · CDSS document, Feb 13, 2024