Villa, The

Licensing Program Analysts (LPAs) Luis De Leon and Mary Flores conducted an unannounced complaint investigation visit for the allegation listed above. LPAs met with the Administrator David Kim and explained the reason for the visit. The investigation consisted of the following: On today’s visit, LPAs Flores, and De Leon obtaining resident and staff rosters, resident #1(R1) admission agreements, physician’s report, staff training, needs and service plan, resident appraisal, order summary report staff’s personal right training provided on 11/22/22, 3/18/08, 10/11/17, and 12/29/16. LPAs review four (4) out (4) staff records and R1’s records. LPAs interviewed five (5) out of thirteen (13) residents and four (4) out of (4) staffs. LPA contacted R1’s responsible party over the phone. (Continue on LIC-9099C) UnsubstantiatedRead the full finding— CDSS inspection report, May 15, 2025 · control 28-AS-20250506090808

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with David Kim (Administrator) and explained the purpose of the visit. During a the initial investigation on 04/08/21, LPA requested a copy of the staff and resident roster and interviewed Staff #1. During today's visit, LPA obtained a copy of the Staff and Resident roster, toured the kitchen and food storage areas with Staff #1 and reviewed records for Residents #1, #2 and #3, interviewed Staff #1, #2 and #3 in the dining room and interviewed Residents #4 to #9 in various locations of the facility. In regards to the allegation: Resident sustained injury while in care. Records review did not indicate an incident of Resident #1 sustaining injury while in care. Interviews with 3 of 3 Staff indicate they are not aware of Resident #1 sustaining injury. Continue to LIC9099C........ UnsubstantiatedRead the full finding— CDSS inspection report, August 4, 2023 · control 28-AS-20210402143323

Licensing Program Analyst (LPA) Kruz Long conducted an unannounced complaint investigation at the facility. Upon arrival, LPA met with David Kim (Administrator) and explained the purpose of the visit. During the initial complaint investigation on 03/30/21, LPA conducted a health and safety check and requested a copy of the Staff and Resident roster. LPA toured the facility via Facetime video with David Kim and observed that the facility is clean and in good repair. There are nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Wash basins, showers/bathtubs and toilets are operable. During today's visit, LPA obtained/reviewed a copy of the Staff schedule, Resident roster, Incident Report, Resident #1's records and Hospice patient incident report. LPA interviewed Staff #1 to #4 in the dining room and interviewed Residents #3 to #8 in their bedrooms. Continue to LIC9099C.... UnsubstantiatedRead the full finding— CDSS inspection report, June 27, 2023 · control 28-AS-20210323093521

**** This amended report supersedes report dated 12/29/2022. It was created to remove confidential information. Revision did not change any other aspects of the report and all aspects remain the same.**** Licensing Program Analyst (LPA) Alberto Lopez initiated a subsequent complaint visit to deliver findings on the allegations listed above. Previous visit was initiated telephonically on 08/04/2020 LPA Almaraz contacted Administrator and requested copies of staff and resident roster along with other pertinent documentation to be emailed to LPA. LPA Lopez made visit on 11/10/2022 and requested 2020 staff and resident’s rosters and asked Administrator for contact information (phone numbers of 2020 staff) and physician’s report for 2020 residents. On 12/20/2022 LPA made another visit to obtain medical/hospice records of several of the residents that resided at facility in 2020. LPA met with Administrator David Kim and discussed the purpose of today’s visit. (continued on 9099C) UnsubstantiRead the full finding— CDSS inspection report, December 29, 2022 · control 28-AS-20200803133247