Villa Lorena

Allegation investigated: Licensee did not meet resident's incontinence needs. Facility did not follow food service requirements.

Licensing Program Analyst (LPA) Arian Golbakhsh conducted an unannounced subsequent visit for a complaint investigation and delivered findings regarding the above mentioned allegations. LPA was welcomed by, identified themselves to, and discussed the purpose of their visit to Business Office Director Denise Nguyen, then Executive Director Nora Garza, who arrived shortly after LPA. On 12/04/2025, the Department received a complaint where it was alleged that the facility left a resident (identified as R1) in a soiled brief for an extended period of time. Additionally, it was alleged that the facility was not following food service requirements, specifically that the facility did not provide a full dinner meal to R1 and that food items in the fridge of R1's unit were not labelled. The Department’s investigation consisted of unannounced facility visits, records review, and interviews with staff, residents, and outside sources. [Continued on LIC 9099-C 1/3] Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 14, 2026 · control 08-AS-20251204154407

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: Resident incurred unexplained bruising while in care. Resident's care needs were not met. Facility did not accord resident with adequate hygiene supplies. Facility did not ensure medical care for resident. Staff did not clean resident's room. Facility staff did not safeguard resident's personal information.

Licensing Program Analyst (LPA) Amy Rodgers met with Administrator Nora Garza to deliver findings on the above-mentioned allegation. LPA identified herself and disclosed the purpose of her visit with Administrator Nora Garza and conducted the meeting via phone call. On June 23, 2022, Community Care Licensing (CCL) received a complaint alleging the above-listed allegations. During the investigation, LPA briefly toured the facility, requested records, and interviewed staff and outside sources. Review of R1’s medical assessment records dated March 11, 2022, revealed that Resident #1(R1) had a diagnosis of dementia as well as a visual impairment, was confused and disoriented, had wandering behavior as well as aggressive behavior. R1 resides in the memory care area of the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 11, 2025 · control 08-AS-20220623102437

Allegation investigated: Physical abuse to resident by staff.

Licensing Program Analyst (LPA) Amy Rodgers met with Administrator Nora Garza to deliver findings on the above-mentioned allegation. LPA identified herself and disclosed the purpose of her visit with Administrator Nora Garza and conducted the meeting via phone call. On November 14, 2024, Community Care Licensing (CCL) received a complaint alleging that the Resident #1(R1) was physically abused by licensee Staff #1(S1) and sustained injuries as a result of the alleged abuse. [See LIC811 Confidential Name List for identification of select person identifiers used in this report]. The Department’s investigation consisted of an unannounced facility visit, records review, and staff, resident, and outside source interviews. (Continued on 9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 11, 2025 · control 08-AS-20241119093137

Allegation investigated: Facility did not provide records to resident's responsible party Facility did not notify resident’s responsible party of an incident Facility did not update resident's records

Licensing Program Analyst (LPA) Amy Rodgers conducted a visit to deliver findings regarding the above-mentioned allegation. LPA was allowed entry by the receptionist. LPA identified herself, met with, and disclosed the purpose of the visit to Administrator Nora Garza. On March 25, 2022, Community Care Licensing (CCL) received a complaint alleging that the facility did not provide records to the resident's responsible party, did not notify the resident’s responsible party of an incident, and did not update the resident's records. During the investigation, the department collected resident records, conducted interviews, and reviewed written correspondence. Based on Resident 1 (R1) Physician’s Report dated April 22, 2022, R1 is diagnosed with Alzheimer's Dementia, and R1 has a designated responsible party. Additionally, R1’s Preplacement Appraisal reveals R1 needs assistance with all dressing and prompting. (continued on LIC9099) Substantiatedthe state’s words, verbatim · CDSS document, Jun 5, 2025 · control 08-AS-20220325123701

Allegation investigated: Staff falsified document

Licensing Program Analyst (LPA) Amy Rodgers conducted an visit to deliver findings regarding the above complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Nora Garza. CCLD’s investigation involved unannounced facility tours, review of relevant records and written correspondence, and interviews with staff and outside sources. On March 18, 2022, Community Care Licensing (CCL) received a complaint alleging that the licensee's staff falsified documents. More specifically, a PRC COVID-19 test was altered for resident #1(R1). Interviews reveal that R1 developed symptoms of COVID 19 prior to an in-person visit by R1's responsible person on 2/12/2022. Interviews with R1's responsible person further reveal R1 was removed from isolation on 2/14/2022. The department conducted a records review for R1 and the charting records for R1 reflect a gap in chart reporting from 1/12/2022 to 3/25/2022. Therefore, the department could nthe state’s words, verbatim · CDSS document, Jun 5, 2025 · control 08-AS-20220318124522

Allegation investigated: Licensee did not assist resident with medication administration Resident was charged for items never provided Licensee did not provide an itemized statement for charges Licensee did not meet resident's transportation needs Housekeeping services did not meet resident's needs License did not meet resident's dining needs

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Nora Garza In February 2022, Community Care Licensing (CCL) received complaints alleging that Licensee staff did not assist a resident with medication administration, the resident was charged for items never provided, Licensee staff did not provide an itemized statement for charges, Licensee did not meet the resident's transportation needs, and License did not meet resident's dining needs. CCLD’s investigation involved unannounced facility tours, review of relevant records and written correspondence, and interviews with staff, residents and outside sources. (Contuned on LIC 9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 5, 2025 · control 08-AS-20220211100740

Allegation investigated: Facility staff handled resident roughly resulting in bruises.

Licensing Program Analyst (LPA), Amy Rodgers, conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA was allowed entry by the receptionist and met with Administrator Nora Garza. LPA identified herself and discussed the purpose of the visit. Investigation was conducted by the Community Care Licensing (CCLD) Investigative Branch (IB) Investigator. The Department’s investigation included a tour of the facility, observations, records reviews, and interviews with staff and outside sources. Prior to the investigation, the CDSS/CCLD/Investigations Branch Investigator interviewed the reporting party and reviewed the facility file. On February 15, 2022, Community Care Licensing (CCL) received a complaint alleging facility staff handled resident roughly resulting in bruises. More specially, that an altercation occurred between Resident #1 (R1) and Staff #1 (S1) that resulted in bruising of R1. (Continued on LIC 9099-C) Substantiatedthe state’s words, verbatim · CDSS document, Jun 5, 2025 · control 08-AS-20220215101301

Allegation investigated: Licensee did not follow COVID-19 guidance Facility was in disrepair Staff spoke inappropriately to residents

Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Administrator Nora Garza OIn February 2022, Community Care Licensing (CCL) received complaints alleging that Licensee staff did not follow COVID-19 guidance, Resident #1(R1) room was in disrepair and licensee staff spoke inappropriately to R1. CCLD’s investigation involved unannounced facility tours, review of relevant records and written correspondence, and interviews with staff, residents and outside sources. [CONTINUED ON LIC 9099-C] Substantiatedthe state’s words, verbatim · CDSS document, Jun 5, 2025 · control 08-AS-20220210154600

Allegation investigated: Licensee did not allow resident to have visitors. Licensee did not safeguard resident's belongings.

Licensing Program Analyst (LPA) Amy Rodgers made an unannounced visit to deliver findings on the above-mentioned allegation. LPA identified herself and disclosed the purpose of her visit with Administrator Nora Garza. On June 6, 2022, Community Care Licensing (CCL) received a complaint alleging that the Licensee did not allow Resident #1(R1) visitors and that the Licensee did not safeguard R1's belongings. During the investigation, LPA briefly toured the facility, requested records, and interviewed staff and outside sources. The review of the physicians report (dated 7/14/2021) reveals R1 has some impairment in hearing and is legally blind. R1 was an assisted living resident. Records review indicate R1 has a history of paranoia and distrust. Interview with staff indicate that R1 has a history of confusion and disorientation. (Continued on 9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 24, 2025 · control 08-AS-20220608130716

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: Licensee did not ensure residents are assessed for proper care placement Lack of supervision resulted in residents eloping Licensee staff did not meet personal care needs for residents

Licensing Program Analysts (LPA) Amy Rodgers conducted an unannouced visit to deliver findings regarding the above-mentioned allegations. LPA introduced themselves and disclosed the purpose of the visit to Resident Service Director Maureen Manzon. On 10/7/2024 it was alleged that Licensee did not ensure residents are assessed for proper care placement and lack of supervision resulted in residents eloping, and licensee staff did not meet personal care needs for residents. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents and outside sources, records review, and LPA observations. It was alleged that Licensee did not ensure residents are assessed for proper care placement for four residents (R1-R4). [See LIC 811 Confidential Names List for a description of R1.] and they should be placed in the memory care unit. A review of facility records reveals there are currently four residents (R1-R4) that reside in the assisted livingthe state’s words, verbatim · CDSS document, Oct 24, 2024 · control 08-AS-20241007110409

Allegation investigated: Facility showers do not dispense hot water Facility has insufficient staffing to meet the needs of residents Staff use objects to obstruct the doorway in the memory care unit The alarm in the memory care unit is in disrepair The facility Administrator is not available a sufficient amount of time to manage the daily operations of the facility Staff are not adequately trained. Lack of supervision resulting in resident eloping from the facility

Licensing Program Analysts (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above-mentioned allegations. LPA introduced themselves and disclosed the purpose of the visit to Resident Service Director Maureen Manzon. On 8/20/2024 it was alleged that Licensee did not ensure showers in memory care unit were at complaint temperatures, there is not enough staffing in memory care which resulted in the licensee not meeting the residents needs, the delayed egress alarm in the memory care unit is not working, the memory care director does not respond to help from staff which effects the daily operations of the facility, staff are not properly trained and lack of supervision resulted in a resident in memory care unit eloping from the facility. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff and outside sources, records review, and LPA observations. (continued on 9099-C] Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 24, 2024 · control 08-AS-20240820121327

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 tampered with resident's personal belongings. Resident was not provided with safe equipment.

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegations. LPA met with Executive Director, Jose Collado Jr. and Memory Care Director, Marie Lou Fikingas. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff and outside sources. It was alleged that staff tampered with Resident #1’s (R1) personal belongings, involving their laptop. R1 had a laptop in their room with an active camera, which was used for Zoom calls with their family. One day a medication technician went to R1’s room to dispense medications and observed themselves on the camera as though it was being recorded. The medication technician left the room and reported the camera to the Executive Director (ED). The ED went to R1’s room to verify if the camera was in use. The ED confirmed the facility does not have cameras in the building as they prefer staff and residethe state’s words, verbatim · CDSS document, Mar 26, 2024 · control 08-AS-20220831154817

Allegation investigated: -Facility does not have adequate staffing to meet resident's needs -Facility is malodorous

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the investigation regarding the above-mentioned allegations. LPA met with Executive Director, Jose Collado Jr. and Memory Care Director, Marie Lou Fikingas. During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged the facility does not have adequate staffing to meet the residents’ needs in the memory care unit. A review of staffing schedules indicated sufficient staffing. Staff interviews confirmed the facility had sufficient staffing. Staff also stated if a staff member calls out then the existing staff will work over one (1)-two (2) hours or a manager will assist. The facility will also use staff from their assisted living portion of the facility when necessary. The Executive Director’s (ED) interview confirmed the facility had sufficient staffing. ED also stated the facility does not use athe state’s words, verbatim · CDSS document, Mar 26, 2024 · control 08-AS-20221031133222

Allegation investigated: Resident eloped Staff not following resident's care plan Staff did not notice resident's change in condition

Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced visit to close out the complaint investigation regarding the above-mentioned allegations. LPA identified herself and met with Jose "Joey" Collado,Executive Director & Amy Salvador Resident Service Director, to discuss the purpose of the visit and elements of the complaint. On or around February 2022, it was alleged that the resident eloped. Interviews revealed Resident 1 (R1) usually takes walks around the facility. Interviews revealed that R1 walks along the perimeter of the facility a few times a day. R1 has not eloped from the facility. The facility is surrounded by a large gate and R1 does walk outside of the facilty and there is a sitting area out there that R1 will go sit at. Interviews revealed if R1 does walk any further staff are close behind. R1 loves to walk/exercise and will walk back and forth. There are no incident reports of R1 eloping from the facility. There were no witness statements to support ththe state’s words, verbatim · CDSS document, Mar 12, 2024 · control 08-AS-20220317135636

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.