Willow View Gardens Memory Care & Assisted Living

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff abandoned resident at hospital

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the visit, LPA interviewed staff and reviewed pertinent documentation such as hospital discharge records. Regarding the allegation that staff abandoned resident at hospital, the investigation revealed the following: Resident 1 (R1) was hospitalized on 10/29/2025 after having a psychotic episode and breaking a window in the resident's room. Per UCI Hospital Social Worker and Psych Consultant RN, resident was medically cleared to return to the facility on 11/03/2025. Facility was contacted for discharge in the morning on 11/03/2025 and was unwilling to accept the resident back. Social Worker stated contacting Ombudsman at that time as well as notifying Licensing via an SOC 341 at 3:07 PM. Administrator contacted LPA on 11/03/2025 at 3:59 PM questionthe state’s words, verbatim · CDSS document, Nov 12, 2025 · control 22-AS-20251104112811

Allegation investigated: - Staff did not provide mail to resident in care

On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. Executive Director (ED) Alma Espinal arrived later to assist with the visit. The Department received a complaint on June 6, 2025. During the investigation, LPA Tea spoke to facility staff and residents and reviewed and collected pertinent documents and information. It was alleged that staff did not provide mail to resident in care. Per interviews with residents, six out eight residents stated that there were no issues with mail services. Most of the residents received their expected mail. A few of the residents complained that their mail was either stolen or went missing. One resident was waiting for a checkbook, and they had never received it. Despite that issue, a staff member was able to get them a replacement checkbook. One resident said beforthe state’s words, verbatim · CDSS document, Sep 12, 2025 · control 22-AS-20250606123601

Allegation investigated: -Facility staff are not ensuring that an appropriately skilled professional is assisting the resident with injections

On this day Licensing Program Analyst (LPA) William Vanegas made an unannounced visit to the facility for the purpose of delivering findings into the investigation of the allegation listed above. LPA Vanegas was greeted and granted entry to the facility by Administrator (AD) Alma Espinal LPA introduced themselves and stated the purpose of the visit. An initial investigation visit was conducted on May 28, 2025. During the visit, LPA Vanegas gathered and reviewed pertinent records pertaining to residents in care in regard to the allegations stated above. LPA Vanegas interviewed residents. LPA Vanegas also gathered and reviewed employee files relevant to the allegations being investigated. The investigation into the allegation, facility staff are not ensuring that an appropriately skilled professional is assisting the resident with injections, revealed the following. It was alleged that facility staff are injecting residents with insulin. No dates or times were provided of when the allegethe state’s words, verbatim · CDSS document, Jun 19, 2025 · control 22-AS-20250520155200

Allegation investigated: Staff did not safeguard resident’s personal belongings.

Licensing Program Manager (LPM) Mota spoke with Alma Espinal, Administrator via telephone visit to discuss the findings for the above allegation. The investigation consisted of interviews with staff, residents, reporting party, and Resident (R1). The investigation also consisted of obtaining Police Records, facility, photographs, and medical records. The investigation revealed the following: An inspection of R1’s room on 5/16/2024 revealed the room to be cluttered with large amounts of clothing and jewelry. Interviews conducted with six (6) out of seven (7) residents stated that they have not had any items missing or stolen from the facility. One (1) resident stated that three (3) items of clothing were missing, but did not feel that they had been stolen, but misplaced. R1 stated during an interview on 5/16/2024 that their entire wardrobe is missing, although photos that same day show many items of clothing on hangars along with shoes, stockings, gold jewelry, and a belt in the room. Rthe state’s words, verbatim · CDSS document, May 27, 2025 · control 22-AS-20240508154100

Allegation investigated: Resident's personal rights were violated.

Licensing Program Analyst (LPA) Jessica Cho arrived at the facility unannounced for the purpose of initiating the complaint investigation into the above allegation. LPA was greeted and granted entry by Housekeeper Alice Castillo and stated the purpose of the visit to Activity Director (AD) Maroma Herrera. During the course of the investigation, LPA interviewed three staff, however the resident in question, (R1), had passed away due to natural causes on May 3, 2025, and could not be interviewed. LPA obtained pertinent records such as the resident/staff rosters, March/May 2025 activity calendars, R1's face sheet, physician's report, admission agreement, death certificate, as well as the employee handbook, and resume of Staff #1 (S1). The investigation revealed the following: Regarding the allegation, Resident's personal rights were violated, it was reported that a TikTok video of R1 and S1 dancing was posted on S1's TikTok account. Based on the review of S1's Tiktok account, there were nthe state’s words, verbatim · CDSS document, May 20, 2025 · control 22-AS-20250515094714

Allegation investigated: Facility did not safeguard resident's personal belongings

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit on this day for the purpose of initiating an investigation into the above allegation. On this day, LPA was greeted and met with Maintenance Director Tony Ruiz. LPA met with Administrator Alma Espinal via telephone. During the course of the investigation, LPA toured the facility and interviewed staff and residents. Regarding the allegation that facility did not safeguard resident's personal belongings, the investigation revealed the following: Facility indicates a pipe repair occurred in the facility on 04/07/2025 which resulted in Resident 1 (R1) being unable to use the resident's toilet for a couple hours. On 04/08/2025, Staff 1 (S1) unclogged the resident's toilet which took about four hours. S1 denies taking any items out of the resident's room. R1's roommate, R2, denies ever having anything taken out of the resident's room and states that R1 did not have any of the noted stolen items in the room at any time. Rthe state’s words, verbatim · CDSS document, May 13, 2025 · control 22-AS-20250507101501

Allegation investigated: Resident sustained unexplained injuries due to lack of supervision Resident sustained unwitnessed fall due to lack of supervision

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit on this day for the purposes of delivering findings into the above allegation. On this day, LPA was greeted and met with Maintenance Director Tony Ruiz. On September 12, 2024, the Department received a complaint alleging Resident sustained unexplained injuries due to lack of supervision; Resident sustained unwitnessed fall due to lack of supervision; and Facility staff did not dispense medications as prescribed. A health and safety visit was conducted by the Department on September 13, 2024, and an investigation initiated. The investigation determined as follows: Resident 1 (R1) was admitted to the facility on August 07, 2024. Per Physician Report dated August 07, 2024, R1 has a diagnosis of generalized weakness and Alzheimer’s disease and requires some assistance with activities of daily living (ADLs) such as bathing, toileting, and dressing. Per Physician Report, R1 requires 24-hour monitoring due to cognitive ithe state’s words, verbatim · CDSS document, Feb 19, 2025 · control 22-AS-20240912142400

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Illegal eviction

Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA interviewed staff and resident. Regarding the allegation of Illegal eviction, the investigation revealed the following: Resident 1 (R1) was served an eviction notice on 04/17/2024 for violation of house rules, alcohol usage. The department approved the eviction notice as legal. The resident as well as two out of two staff confirm alcohol usage in the resident's room. Resident 1 initially denied receipt of eviction notice but openly discussed the terms of the notice and the violation with LPA. Based on interviews conducted and record review, the allegation is deemed unfounded, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interview conducted and a copy of this rethe state’s words, verbatim · CDSS document, May 7, 2024 · control 22-AS-20240502094405

Allegation investigated: Staff did not provide comfortable living accommodations for resident

Licensing Program Analysts (LPAs) Kimberly Lyman and Michael Tea made an unannounced complaint visit to initiate an investigation into the above allegation. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPAs toured the facility and interviewed staff and residents. Regarding the allegation that staff did not provide comfortable living accommodations for resident, the investigation revealed the following: Residents 1 and 2 (R1, R2) became roommates on 04/12/2024. On 04/26/2024, staff informed Administrator that the residents were arguing and unhappy with the living situation. Administrator spoke with both residents same day to come up with a solution. On 04/30/2024, Administrator spoke with residents to advise they would be residing in separate rooms. LPA observed staff getting R2's room ready and moving personal affects. Both residents confirm acceptance of the move. Facility indicates this is the sithe state’s words, verbatim · CDSS document, May 1, 2024 · control 22-AS-20240426103500

Allegation investigated: Staff did not assist resident with meeting dining needs Staff do not provide adequate activities for residents

Licensing Program Analysts (LPAs) Kimberly Lyman and Michael Tea made an unannounced complaint visit to initiate an investigation into the above allegations. LPAs were greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPAs toured the facility and interviewed staff and residents as well as reviewed and obtained pertinent documentation such as activities schedule. Regarding the allegations that staff did not assist resident with meeting dining needs and staff do not provide adequate activities for residents, the investigation revealed the following: On 04/17/2024, facility had a dining staff call out. Administrator as well as Activity Coordinator pitched in to serve the residents lunch. There are no activities during lunch time. Six out of six residents confirm receipt of lunch and the server call out had no impact on receiving lunch or participating in activities. Six out of six residents state ample activities atthe state’s words, verbatim · CDSS document, May 1, 2024 · control 22-AS-20240418134733

Allegation investigated: Staff did not seek timely medical attention for resident.

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA interviewed staff and witnesses as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegation that staff did not seek timely medical attention for resident, the investigation revealed the following: Resident 1 (R1) admitted into the facility on 03/27/2024 with a diagnosis of Parkinson's Disease. Resident was hospitalized at Kaiser prior to admittance into facility. When resident admitted into the facility, Kaiser failed to provide medication/ medication orders. Facility and family were working on getting the situation remedied. On 03/29/2024, R1 was observed by staff on the ground by the resident's bed in the resident's room. Staff assisted getting the resident up and was assethe state’s words, verbatim · CDSS document, Apr 16, 2024 · control 22-AS-20240402090752

Allegation investigated: Staff did not provide a resident an admission agreement

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed staff as well as reviewed and obtained pertinent documentation such as admission agreement. Regarding the allegation that staff did not provide a resident an admission agreement, the investigation revealed the following: Resident 1 (R1) admitted into the facility on 02/29/2024 and admission agreement on file at facility is signed and dated by R1 on 02/29/2024. Billing invoice is dated 02/29/2024-03/31/2024. Administrator indicates admission agreement was signed at time of admission on 02/29/2024. Based on record review and interviews conducted, the allegation is deemed unfounded, meaning the allegation was false, could not have happened and/or is without a reasonable basis. Exit interviewthe state’s words, verbatim · CDSS document, Apr 16, 2024 · control 22-AS-20240405084807

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not follow proper eviction procedures

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA interviewed staff and resident as well as reviewed and obtained pertinent documentation such as text messages. Regarding the allegation that staff did not follow proper eviction procedures, the investigation revealed the following: Resident 1 (R1) moved out of the facility on 02/24/2024 with the resident's family member who is also the durable power of attorney (DPOA). DPOA provided a 30 day notice to the facility via text message but moved the resident out same day. Interview with resident indicated the resident is happy and satisfied with the move out of facility. Administrator as well as witness confirm resident was not evicted out of the facility and moved out voluntarily. Based on record review and intervithe state’s words, verbatim · CDSS document, Mar 12, 2024 · control 22-AS-20240306123021

Allegation investigated: Staff inappropriately placed resident on an involuntary 72hr hold Staff did not provide resident with keys in a timely manner Staff are not providing activities for residents Staff are not allowing resident to leave the facility

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as psychiatric hospital documentation. Regarding the allegations that staff inappropriately placed resident on an involuntary 72hr hold, staff did not provide resident with keys in a timely manner, staff are not providing activities for residents and staff are not allowing resident to leave the facility, the investigation revealed the following: Resident 1 (R1) was evaluated by a mental health professional on 06/10/2023 due to increaing behaviors and was sent out to LA Downtown Medical Center for a 72 hour hold. Resident was transferred to the medical center as the resident was deemed to have a grave disabilthe state’s words, verbatim · CDSS document, Feb 27, 2024 · control 22-AS-20240215130307

Allegation investigated: Staff does not serve dinner to residents at an appropriate time Staff does not ensure that residents' food is served warm Staff are not able to effectively communicate with the residents due to a language barrier

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the investigation, LPA toured the kitchen, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as room meal delivery list. Regarding the allegations that staff does not serve dinner to residents at an appropriate time, staff does not ensure that residents' food is served warm, and staff are not able to effectively communicate with the residents due to a language barrier, the investigation revealed the following: LPA toured the kitchen and observed food supply on-site on two different occasions. On both occasions there is adequate food supply available. LPA observed food warmers in kitchen as well as the process to send out delivered meals. Six out of seven residents state food is warm when delivered to the room. Admthe state’s words, verbatim · CDSS document, Feb 22, 2024 · control 22-AS-20240201105417

Allegation investigated: Staff are not allowing resident to participate in the planning of their care

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed staff and witness as well as reviewed and obtained pertinent documentation such as durable power of attorney and physician report. Regarding the allegation that staff are not allowing resident to participate in the planning of their care, the investigation revealed the following: Resident 1 (R1) has a responsible party per power of attorney paperwork dated 03/02/2016. Facility administrator acknowledges resident's power of attorney. Resident was signed up for hospice care in the facility effective 10/06/2023 without approval or consultation with responsible party who acts as an agent for the resident. R1's responsible party was only informed of the enrollment when the resident's insurancethe state’s words, verbatim · CDSS document, Dec 13, 2023 · control 22-AS-20231122171857

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility illegally evicted resident

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegation. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed resident and staff as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegation that facility illegally evicted resident, the investigation revealed the following: Facility gave Resident 1 (R1) a thirty day eviction notice dated 10/20/2023 indicating the reason for eviction was "Refusing to log in personal/ valuable properties as inventoried items." Facility admission agreement states that facility will only inventory/ provide an inventory log if resident's property is entrusted to the care of the facility. Resident has no items entrusted to the care of the facility. The eviction notice is not legal per department guidelines. The prthe state’s words, verbatim · CDSS document, Oct 26, 2023 · control 22-AS-20231023121324

Allegation investigated: Facility did not ensure resident's medication was administered correctly Facility does not have sufficient staffing Resident room has a cigarette odor

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to initiate an investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed staff and residents as well as reviewed and obtained pertinent documentation such as physician report and staff schedule. Regarding the allegations that resident room has a cigarette odor, facility does not have sufficient staffing and facility did not ensure resident's medication was administered correctly, the investigation revealed the following: Resident 1's (R1) room is on the opposite side of the designated smoking area. R1 indicates residents smoke after hours in the courtyard below resident's room. Administrator acknowledges discovering a resident had smoked in the un-designated area and facility has taken steps to ensure all smoking is occurring in the designated area.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 22-AS-20231003163937

Allegation investigated: Facility does not have adequate staffing to meet resident care needs Staff do not attend to residents in a timely manner Residents are not provided with activities Residents are not provided adequate shower assistance

Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit. During the course of the investigation, LPA toured the facility, interviewed staff, residents and witnesses as well as reviewed and obtained pertinent documentation such as staff schedule. Regarding the allegations that facility does not have adequate staffing to meet resident care needs, staff do not attend to residents in a timely manner, residents are not provided with activities and residents are not provided adequate shower assistance, the investigation revealed the following: Eight out of nine residents interviewed indicate a staffing shortage and state caregivers are working as dining room servers. Staff and Administrator confirm caregivers are filling in as servers and activity coordinators. Staff indicate working two per shift with a med tech. Facility hathe state’s words, verbatim · CDSS document, Aug 21, 2023 · control 22-AS-20230731155923