Westfield Villa Gardens

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Other

On 08/18/26 Licensing Program Analyst (LPA) Sarina Ramirez arrived at the facility to amend documents originally delivered on 04/20/26. On 04/20/26 LPA Ramirez was at the facility to initiate a complaint investigation COMPLAINT CONTROL NUMBER: 56-AS-20260105143713 The amendment was signed by Caregiver Dexinia Cruz and was provided a copy of the amended report at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 18, 2026

Allegation investigated: Resident sustained multiple bruises/facial fracture due to staff neglect or physical abuse

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to deliver findings on the allegation mentioned. LPA met with Caregiver Dexinia Cruz and explained the purpose of the visit. The Department's investigation involved interviews and records review. Regarding allegation, it is alleged resident sustained multiple bruises/facial fracture due to staff neglect or physical abuse. Resident#1 (R1) experienced a fall on 12/29/2025, and hospital imaging at that time showed no fractures. On 01/02/2026, staff observed swelling and bruising on R1’s left hand and sent them to the hospital, where imaging revealed a left thumb fracture, nasal bone fracture, and shingles—injuries not present during the prior visit. The facility could not determine how the fractures occurred or whether an unwitnessed fall took place. Staff responded promptly by sending the resident out for evaluation, and the administrator reclassified the resident as a fall risk following their second hospitalization. Unsubstantiated LPA conducted interviews with five (5) residents all (5) have stated they have not fallen while living at the facility; nor do staff neglect the residents in care. LPA conducted three (3) staff interviews all whom confirm they have not neglected residents nor have they seen or heard residents sustaining bruises/fractures due to staff neglect. Based on the information obtained, there is insufficient evidence to support the allegation that the facility failed to provide adequate care and supervision. The allegation of neglect/lack of care or physical abuse is Unsubstantiated. This means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed, and a copy was provided to Caregiver Dexinia Cruz at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 20, 2026 · control 56-AS-20260105143713

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Gemma Falls, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (50), a current census of (33). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility does not have a swimming pool or similar bodies of water. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities. The facility is equipped with operating smoke detectors/carbon monoxide alarms, working laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in four (4) resident bathrooms measured between 107.1 and 116.2 degrees F. Five (5) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, Personal Rights, Monthly Menu, Monthly Activities, facility sketch, CCLD complaint poster, and Ombudsman poster. Food Service: Facility kitchen and dining area are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps and chemicals were kept locked and inaccessible to residents in care. Continuation on LIC – 809C: Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff working have current CPR/first aid training and background cleared. Medical Related Services: Resident’s medications are labeled and centrally stored in a locked room. LPA audited four (4) residents medication at random, staff signed PM medication(s) by accident; however medication was not dispensed, Technical Violation issued. Record Review: Four (4) Staff files reviewed were observed to be complete. Four (4) Resident files reviewed were observed to be complete. Last disaster drill was conducted March 8,2026. Fire Marshall conducted their quarterly visit on 3/17/26 with no deficiencies. Based on observations and record review one (1) technical violation issued, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Administrator Alma Gemma Falls at the conclusion of the visit.the state’s words, verbatim · CDSS document, Apr 20, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff are not bathing residents in accordance with their individual care needs Staff are not ensuring the facility remains free of incontinence odors. Staff are not ensuring resident's personal items are safeguarded

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to conduct a complaint investigation on the above allegations. LPA met with Administrator Gemma Falls, and discussed the purpose of the visit. Regarding allegation #1, LPA interviewed eight (8) residents. Six (6) of the eight (8) residents agreed staff provide them with enough showers a week. 1 of the 8 residents informed LPA they are sick and cannot take many showers, and 1 of the 8 residents informed LPA they do not receive enough showers from staff. LPA interviewed five (5) staff, all 5 have agreed they provide residents with 2-3 showers a week. Regarding allegation #2, LPA observed staff cleaning the facility, the facility was free of incontinence odor and smelled like cleaning solutions. Unsubstantiated LPA interviewed eight (8) residents. Seven (7) of the eight (8) residents agreed the facility does not smell bad, one (1) of the eight (8) residents stated the facility smells. LPA interviewed five (5) staff, all whom stated they ensure the facility does not smell like incontinence odor. Staff informed LPA if residents have accidents, the residents and facility is cleaned immediately. Regarding allegation #3, LPA interviewed eight (8) residents, all who stated their belongings are safeguarded in their rooms. LPA interviewed five (5) staff, all whom stated they have not heard of residents items gone missing, all items are kept in resident’s closets. Staff ensure to redirect residents who wander into rooms that are not theirs. Based on LPA’s observations, staff and resident interviews, and relevant documentation, the allegations are determined to be Unsubstantiated. An Unsubstantiated finding means that although the allegations may be valid or could have occurred, there is insufficient evidence to support that the alleged violation did or did not happen. An exit interview was conducted with Administrator, and a copy of this report was provided at the conclusion of the visit.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 56-AS-20251125140816

Allegation investigated: Licensee is not adhering to proper eviction protocols with residents in care Staff are not reporting incidents involving residents in care

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to conduct complaint investigation on the above allegations. LPA met with Administrator, Alma Espinal who was informed of today’s visit. The investigation consisted of LPA observations, reviewing pertinent records, and interviews with relevant parties. Regarding the allegation, Licensee is not adhering to proper eviction protocols with residents in care, it was alleged that Resident #1 (R1), Resident #2 (R2), and Resident #3 (R3) were not provided relocation assistance after being served eviction. A review of facility records reveals that R1 and R2 were issued 30-day eviction notices, which included a referral list for residential care housing. Interviews with staff and a review of records revealed that R3 was not given an eviction notice, as R3’s family voluntarily discharged the resident from the facility. Therefore, there is not enough evidence to corroborate the allegation. **continued on LIC9099C** Unsubstantiated Regarding the allegation, staff are not reporting incidents involving residents in care, It was alleged that staff did not report a fall incident involving Resident #3 (R3) to R3’s authorized representative in a timely manner. Review of facility records reveals that on March 7, 2024, R3 sustained a fall at the facility. Interviews with staff reveal that R3’s authorized representative was informed of the fall on the same day. Additionally, an incident report was submitted by facility staff to the Community Care Licensing Division (CCLD) regional office on March 7, 2024. Therefore, there is not enough evidence to corroborate the allegation. Based the Department's investigation, the allegations are Unsubstantiated. Unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted, during which this report was discussed, and a copy with appeal rights was provided to Administrator Espinal at the conclusion of the visitthe state’s words, verbatim · CDSS document, Oct 23, 2025 · control 56-AS-20240326152021

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Magda Malcore conducted an case management and met with Administrator Alma Espinal to address information obtained during complaint investigation #56-AS-20240326152021. The information obtained was unrelated to the complaint allegations. LPA obtained information that staff #1 (S1) did not speak to a resident with dignity. S1 no longer works at the facility and was not interviewed. Interviews with five (5) staff and five (5) residents reveals not enough evidence to corroborate that S1 did not speak to a resident with dignity. LPA obtained information that staff are administering injections to a resident in care. Five (5) staff interviewed deny administering injections to a resident in care. Five (5) residents interviewed deny that staff are administering injections to them. No deficiencies were cited during today's visit. An exit interview was conducted where this report discussed and a copy provided to Administrator Espinal at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 23, 2025

Allegation investigated: Staff do not meet a resident's dental needs Staff do not meet a resident's physical therapy needs Staff do not meet a resident's dietary needs Staff do not provide adequate care and supervision to a resident

Licensing Program Analyst (LPA) Sarina Ramirez conducted an unannounced visit to the facility to deliver findings on a complaint investigation regarding the above allegations. LPA met with Administrator Gemma Falls and discussed the purpose of the visit. Regarding allegation #1, LPA conducted eight (8) resident interviews. Four (4) residents confirmed they brush their own teeth, three (3) residents don’t have any teeth, one (1) resident stated staff are not brushing resident’s teeth. LPA conducted three (3) staff interviews, all of whom confirmed they meet the dental needs for residents, although some refuse or bite the toothbrush. Regarding allegation #2, LPA conducted 8 resident interviews. 7 of the 8 confirmed they do not need physical therapy, and choose not to exercise. 1 of the 8 residents stated physical therapy needs are not being met. Unsubstantiated LPA conducted 3 staff interviews, all whom confirmed the residents in care do not require physical therapy as ordered by a doctor. Staff encourage residents to exercise however most refuse. LPA observed a seated work out video playing in the dining room as 3 residents sat while the work out video played, but none were participating. Regarding allegation #3, LPA conducted 8 resident interviews. 7 of the 8 residents confirmed they are not on special diets. 1 of the 8 residents stated dietary needs are not being met. LPA conducted 3 staff interviews, all whom confirmed they follow residents dietary needs. Regarding allegation #4, LPA conducted 8 resident interviews. 7 of the 8 confirm facility has enough care and supervision. 1 of the 8 residents stated there is not enough care and supervision. LPA conducted 3 staff interviews, all whom confirm they have enough staff and supervision for residents in care. Based on LPA's observations, record reviews, and interviews, the above allegations are unsubstantiated. This means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. An exit interview was conducted where this report was discussed, and a copy was provided to Administrator Gemma Falls at the conclusion of the visit.the state’s words, verbatim · CDSS document, Jun 11, 2025 · control 56-AS-20240826141555

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sarina Ramirez made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Administrator Alma Espinal, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with a license capacity of (50), a current census of (38). LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility does not have a swimming pool or similar bodies of water. The facility has sufficient lighting and is maintained at a comfortable temperature. The facility has sufficient indoor and outdoor space for resident activities. The facility is equipped with operating smoke detectors/carbon monoxide alarms, working laundry equipment, and telephone service. Resident’s showers, toilets, and hand washing areas were operating properly. The hot water temperature in two (2) resident bathrooms and kitchen measured between 106 and 108.3 degrees F. Fourteen (14) resident’s bedrooms had beds, bed linen, chairs, dresser, storage space and sufficient lighting. The facility has sufficient linens, towels, and personal hygiene items for residents. The facility has posted in a common area, facility license, Personal Rights, Monthly Menu, Monthly Activities, facility sketch, CCLD complaint poster, and Ombudsman poster. Food Service: Facility kitchen and dining area are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. Sharps and chemicals were kept locked and inaccessible to residents in care. Continuation on LIC – 809C: Care & Supervision: Facility has 24-hour/7days a week care staff. Facility staff have current CPR/first aid training. Medical Related Services: Resident’s medications are labeled and centrally stored in a locked cabinet. Record Review: Six (6) Staff files reviewed were observed to be complete. Five (5) Resident files reviewed were observed to be complete. Based on observations and record review no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted, and this report was discussed and provided to Administrator Alma Espinal.the state’s words, verbatim · CDSS document, Apr 4, 2025

Allegation investigated: Staff does not ensure resident's showering needs are being met. Staff does not provide resident adequate food service Staff does not safeguard resident's personal belongings Staff left resident in soiled diaper for an extended period of time

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to conclude the complaint investigation. LPA met with Supervisor, Gemma Falls and discussed the purpose of the visit. The investigation consisted of LPA record review, interviews with residents and staff. Regarding the allegation, staff does not ensure resident's showering needs are being met, four (4) staff interviewed deny not ensuring resident's showering needs are being met. Five (5) out of (6) residents interviewed stated that their showering needs are being met. Regarding the allegation, staff does not provide resident adequate food service, it was alleged that hot food is not served at appropriate temperatures. Four (4) staff interviewed deny that hot food is not served at appropriate temperatures. Four (4) out of (6) residents interviewed stated that hot food is served at appropriate temperatures. Unsubstantiated Regarding the allegation, staff does not safeguard resident's personal belongings, it was alleged that resident #1 (R1) had a chair cushion stolen at the facility. LPA record review, interviews with four (4) staff and six (6) residents reveals not enough evidence to corroborate the allegation. Regarding the allegation, staff left resident in soiled diaper for an extended period of time, four (4) staff interviewed deny leaving residents in soiled diapers for an extended period of time. Five (5) out of (6) residents interviewed stated that they have not be left in soiled diapers for an extended period of time. Based on evidence obtained during this investigation, the allegation above is Unsubstantiated; meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted where this report was discussed and a copy of this report was provided with appeal rights to Supervisor Falls at the conclusion of the visit.the state’s words, verbatim · CDSS document, Oct 16, 2024 · control 56-AS-20240507133354

Allegation investigated: Facility staff are not assisting resident with hygiene needs

Licensing Program Analyst (LPA) Magda Malcore conducted an unannouced complaint visit to the facility. LPA met with Alma Espinal, Administrator, and was informed of the visit. Regarding the allegation, facility staff are not assisting resident with hygiene needs, During today's visit, LPA observed ants on resident #1(R1's) mattress. R1 lifted their pillow and several ants were observed on the pillow. Two (2) staff immediately changed the linen and mopped the floors. Interviews with staff reveal that R1 often eats in his bed and could be attracting the ants. LPA record review reveals, on 6/29/24, R1 was seen by a medical professional who described R1 as having poor personal hygiene. Based on LPA record review and observations, the allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met. An exit interview was conducted where reports (LIC9099&LIC9099-D) were discussed and provided with appeal rights to the Administrator at the conclusion of the visit. Substantiatedthe state’s words, verbatim · CDSS document, Aug 1, 2024 · control 56-AS-20240531155038

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Aug 2, 2024

87307 Personal Accommodations and Services.(a)Living accommodations...shall be related to the facility's function... Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available...(C)clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, ...shall be sufficient to permit changing at least once per week or more often...to ensure that clean linen is in use by residents at all times..This requirement is not met as evidenced by: The Licensee did not comply with the section cited by R1 had several ants on bed and assessed with poor hygiene, which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Aug 1, 2024

Plan of correction: Two staff immediately changed R1's bed linen and mopped the floors. The Licensee and/or Administrator shall submit to the Licensing Agency a written certification of understanding on the regulation cited by POC date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced follow-up visit to gather information pertaining to complaint #56-AS-20240531155038 investigation. LPA met with Gemma Falls, Staff, and discussed the purpose of the visit. During today’s visit LPA conducted interviews and obtained copies of relevant documents. An exit interview was conducted where this report was discussed and a copy of this report was provided to staff Falls at the conclusion of the visit.the state’s words, verbatim · CDSS document, Aug 1, 2024

Allegation investigated: Staff did not provide adequate supervision, resulting in a resident being threatened by other residents. Staff did not ensure that a resident received medical services. Staff left a resident in a wheelchair for extended periods of time.

On 03/28/2024 at 01:30 PM, Licensing Program Analysts (LPAs) Melody Brown and Sarina Ramirez met with Administrator Maria Jasmin Dolores at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office to deliver the findings of the above allegations. LPAs Brown and Ramirez explained the purpose of the requested Office Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation. The investigation was conducted by LPA Melody Brown. The investigation consisted of records review and interviews with relevant parties. The first allegation indicates that Staff did not provide adequate supervision, resulting in a resident being threatened by other residents. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with four (4) of four (4) residents indicated that all staffs at the facility are providing them adequate supervision and all residents interviewed reported that they did not know of an incident that a resident at the facility was threatened by another resident. LPA Brown unable to interview Resident #1 (R1) as R1 refused to be interviewed. *** Continuation in LIC9099C *** Unsubstantiated Interviews with six (6) of six (6) staffs indicated that they are all providing adequate supervision to all their residents at the facility, and they all reported that they are all checking on their residents at least every two (2) hours more often if needed. Staffs’ interviews revealed that no incident happened at the facility that a resident was threatened by another resident. Records review indicated that staffs are checking on residents every two (2) hours. During the facility visit on 03/25/2024, LPA Brown observed caregivers checking on residents while doing their rounds. The second allegation indicates Staff did not ensure that a resident received medical services. Interviews with four (4) of four (4) residents indicated that all staffs at the facility are making sure that they all received their medical services and there's no incident that happened that a staff did not ensure that they did receive their medical services. LPA Brown unable to interview Resident #1 (R1) as R1 refused to be interviewed. Interviews with six (6) of six (6) staffs indicated that all staffs at the facility ensure that all their residents received their medical services, that all residents will go to their medical appointments. All staff interviewed reported that no incident happened at the facility that they did not ensure that a resident will receive their medical service because all of their residents are receiving their medical service on time and per schedule. Records review indicated that staffs at the facility are ensuring that the residents are receiving their medical services. The third allegation indicates Staff left a resident in a wheelchair for extended periods of time. During the investigation, LPA Brown did not find evidence to corroborate the allegation. Interviews with four (4) of four (4) residents indicated that they did not witness a staff at the facility leaving a resident in a wheelchair for extended periods of time. LPA Brown unable to interview Resident #1 (R1) as R1 refused to be interviewed. Interviews with six (6) of six (6) staffs indicated that no staff at the facility leaves a resident on wheelchair for extended periods of time. Interviews with staffs revealed that residents have their set schedule that they follow and their residents participate in the daily activities. Staffs interviewed reported to LPA Brown that there's no incident happened at the facility that a resident was left on a wheelchair for extended period of time. During the visit on 03/25/2024, LPA Brown observed no resident at the facility left on wheelchair by a staff for extended period of time. *** Continuation in LIC9099C *** Based on the evidence, the allegation that Staff did not provide adequate supervision, resulting in a resident being threatened by other residents (Allegation #1), Staff did not ensure that a resident received medical services (Allegation #2), Staff left a resident in a wheelchair for extended periods of time (Allegation #3) are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time. An exit interview was conducted where this report, LIC9099 was discussed and provided to Administrator Maria Jasmin Dolores.the state’s words, verbatim · CDSS document, Mar 28, 2024 · control 56-AS-20240321085554

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Maria Jasmin Dolores, Administrator, and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) with (3) floor levels. The facility has a license capacity of (50) non-ambulatory residents, a current census of (33) residents in care, and a hospice waiver for (30) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: Physical Plant/Environment: Indoor and outdoor passageways are free of obstruction. The facility has no swimming pools or similar bodies of water. Outdoor activity area is sufficient for resident activities and is enclosed with self-latching gates. The facility is maintained at a comfortable temperature. Resident bathrooms audited were equipped with grab rails and non-skid mats. Resident bathroom showers, toilets, and hand washing areas were operating properly and the hot water temperature measured 117 degrees F. Resident bedrooms audited had beds, chairs, nightstands, and sufficient lighting; However, a deficiency is being cited for not maintaining bedroom #19 clean and free of odors. Facility staff stated that they have scheduled an appointment for tomorrow (3/12/24) with an outside service company to have the carpet in bedroom #19 cleaned and sanitized. The facility has operating carbon monoxide alarms, laundry equipment, telephone service, and each floor level has an operating signal system. The facility has sufficient linen, towels, and personal hygiene items for residents. The facility has posted in a common area, Community Care Licensing complaint poster, Ombudsman poster, resident activities, evacuation exit plan and emergency telephone numbers. Sharps, disinfectants, and cleaning solutions were kept locked and inaccessible to residents in care. Care & Supervision: Facility has 24-hour, 7 days a week care staff. Food Service: Facility kitchen and dining areas are maintained clean. The facility has sufficient non-perishable and perishable food supply for residents in care. The facility has posted in the kitchen a list of residents with modified diets. The facility has menus posted in the dining area. Record Review: (6) staff files audited had criminal record clearances, health screening, employment applications, and current first aid/CPR training. (6) resident files audited had admissions agreements, physician's reports, assessments, theft and loss policy, and personal rights statements. The facility’s Administrator’s certification and liability insurance are current. The facility has an infection control and an emergency disaster plan on file. The facility’s last fire drill was conducted on 1/10/24. Medical Related Services: (6) Resident’s medications audited were labeled and centrally stored in a locked cabinet. The facility had first aid kits and first aid manuals. Based on observations and record review, a deficiency is being cited per Title 22, of The California Code of Regulations. An exit interview was conducted where this report and a plan of correction was discussed with Administrator Dolores. A copy of this report was provided with Appeal Rights to the Administrator at the conclusion of the visit.the state’s words, verbatim · CDSS document, Mar 11, 2024

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.