Inspection Reports for
Las Villas del Norte

The visit was complaint-related due to an incident where Resident 1 eloped from the facility after a fire alarm was pulled, disarming exit doors. Resident 1 was located by law enforcement a mile away and returned safely. Resident 1 is unable to leave unassisted and has a history of eloping. Civil penalties will be assessed.

The fire alarm pull caused all exit doors to disarm, allowing Resident 1 to elope from the facility without staff supervision. Resident 1 was found a mile away by law enforcement and returned safely. A similar incident occurred with Resident 2 on 2025-03-30. Civil penalties will be assessed. No additional health or safety concerns were observed.

The visit was complaint-related due to an incident where Resident 1 eloped from the facility after a fire alarm was pulled, disarming exit doors. Resident 1 was located by law enforcement a mile away. Resident 1 has a history of eloping and is unable to leave unassisted. The complaint is substantiated as civil penalties will be assessed.

The fire alarm near the memory care unit was pulled, causing exit doors to disarm and Resident 1 to elope without staff supervision. Resident 1 was found a mile away by law enforcement with no apparent injuries. A similar incident occurred with Resident 2 on 2025-03-30. Civil penalties will be assessed. No additional health or safety concerns were observed.

The visit was complaint-related due to an incident where Resident 1 eloped from the facility on 2025-03-30. The resident was returned by law enforcement and assessed with no visible injuries. The complaint was substantiated by the finding that staff failed to secure the courtyard gate.

Facility staff failed to ensure the courtyard gate was secured after a fire alarm disarmed all exit doors, resulting in Resident 1 eloping from the facility without staff supervision. The resident was returned by law enforcement with no visible injuries. The facility conducted staff training and purchased a new siren alarm for the courtyard gate but was cited for noncompliance with California Code of Regulations 87705(e)(5). No health or safety concerns were observed during the visit.

The visit was complaint-related due to an incident where Resident 1 eloped from the facility on 2025-03-30. The complaint was substantiated as the facility failed to secure the courtyard gate, posing a potential health and safety risk.

Facility staff failed to ensure the courtyard gate was secured after all exit doors were disarmed due to a fire alarm, resulting in Resident 1 eloping from the facility without staff supervision. The resident was returned by law enforcement with no visible injuries. The facility conducted staff training and purchased a new siren alarm for the courtyard gate.

The complaint investigation was substantiated for the allegation that the licensee did not provide healthful accommodations for a resident. The allegations that staff were not properly trained in cleaning/sanitation practices and that a resident was not accorded dignity were unsubstantiated.

The investigation substantiated that the licensee failed to provide healthful and comfortable accommodations for one resident in the memory care unit, evidenced by ants crawling on the resident and bedding. Other allegations regarding staff training and resident dignity were unsubstantiated due to lack of supporting evidence.

The complaint investigation was substantiated for the allegation that the licensee did not provide healthful accommodations for a resident, specifically ants crawling on the resident and bedding. The allegations that staff were not properly trained in cleaning/sanitation and that a resident was not accorded dignity were unsubstantiated.

The investigation found that the allegation regarding failure to provide healthful accommodations was substantiated based on evidence of ants crawling on a resident and their bedding in the memory care unit. The allegations regarding improper staff training in cleaning/sanitation and lack of dignity to the resident were unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for the allegation that staff did not ensure the facility was clean, specifically the Memory Care Unit. The allegation that staff did not properly store food was unsubstantiated due to lack of evidence.

The investigation substantiated that housekeeping staff did not ensure the Memory Care Unit was properly cleaned, with feces observed in multiple resident bathrooms and common areas. The allegation regarding improper food storage was unsubstantiated as food was stored properly and only one of nine interviews corroborated the claim.

The complaint investigation was substantiated for the allegation that staff did not ensure the facility was clean, specifically in the Memory Care Unit. The allegation regarding improper food storage causing residents to get sick was unsubstantiated due to lack of evidence.

The investigation substantiated the allegation that housekeeping staff did not ensure the Memory Care Unit was properly cleaned, with feces observed in multiple resident bathrooms and showers. The facility reported staffing shortages but has since hired additional housekeepers. The allegation that residents got sick from improperly stored food was unsubstantiated after inspection and interviews.

The inspection revealed that three out of three reviewed memory care staff did not complete the required twelve hours of dementia care training, posing an immediate health, safety, and personal rights risk to residents.

The inspection revealed that three out of three reviewed staff did not complete the required twelve hours of dementia care training, posing an immediate health, safety, and personal rights risk to residents.

The complaint alleging that staff overcharged a resident for care was substantiated based on interviews and record review. The overcharge occurred during the resident's absence from April 17, 2023 to July 7, 2023, and was due to a clerical error.

The investigation substantiated that Resident 1 was overcharged $3,400.00 in monthly care fees due to a clerical error, despite the facility's admission agreement requiring a pro-rated credit for absences over fourteen days. The facility will be cited for noncompliance with California Code of Regulations, Title 22, regulation 87507(f).

The complaint alleged that staff overcharged a resident for care fees during an absence exceeding fourteen days due to hospitalization. The allegation was substantiated based on interviews and record review.

The investigation substantiated that Resident 1 was overcharged $3,400.00 in monthly care fees due to a clerical error, despite the facility not acting in bad faith. The facility failed to comply with the admission agreement's terms on pro-rated credits for absences over fourteen days.

The complaint investigation was unannounced and addressed multiple allegations including severe neglect, unsupervised resident, irregular feeding, and unsafe environment. The allegation regarding unsafe environment was substantiated, while others were unsubstantiated. The report notes the preponderance of evidence standard was met for the substantiated allegation.

The investigation found the allegation of an unsafe and unclean environment substantiated due to a soiled mattress stored in a resident's bathroom posing health and safety risks. Allegations of severe neglect, lack of supervision, and irregular feeding were unsubstantiated based on staff interviews, resident records, and observations.

The complaint investigation was triggered by allegations including severe neglect, unsupervised resident, irregular feeding, and unsafe/unclean environment. The allegations of neglect, supervision, and feeding were unsubstantiated. The unsafe and unclean environment allegation was substantiated.

The investigation found the allegations of severe neglect, unsupervised resident, and irregular feeding to be unsubstantiated due to lack of sufficient evidence. However, the allegation that the facility did not provide a safe and clean environment was substantiated based on the presence of a soiled mattress stored in a resident's bathroom, posing health and safety risks.

The complaint was substantiated based on evidence that residents #1 and #2 did not receive their mail for approximately four months, violating their personal rights.

The investigation found that residents #1 and #2 had accumulated approximately four months of mail that was not provided to them or their responsible parties, substantiating the allegation of a Personal Rights Violation.

The complaint was substantiated based on interviews with staff, residents' responsible parties, and family representatives, confirming mail was not provided for at least four months.

The investigation found that residents #1 and #2 had accumulated approximately four months of mail that was not provided to them or their responsible parties, substantiating the allegation of a Personal Rights Violation.

The visit was triggered by complaint control number 18-AS-20220922143233. The complaint involved multiple falls of Resident #1 between May 24 and May 26, 2022, and failure of the facility to reassess and implement fall precautions. The deficiency was substantiated.

The facility failed to address a change in Resident #1's condition and did not conduct a reassessment for fall precautions despite multiple falls occurring in less than 48 hours, posing a potential threat to resident safety.

The complaint investigation was substantiated for the allegation that staff did not answer the resident's call button in a timely manner, with documented response times of 35 and 39 minutes. Other allegations regarding multiple falls due to lack of supervision, unsafe environment, failure to assist with changing clothes, and medication dispensing were unsubstantiated or unfounded.

The investigation substantiated that staff did not respond to a resident's call button in a timely manner, posing a potential health and safety risk. Other allegations including lack of supervision leading to falls, unsafe environment, failure to assist with changing clothes, and medication dispensing were found unsubstantiated or unfounded.

The visit was triggered by complaint control number 18-AS-20220922143233. The deficiency was substantiated as the facility failed to address the resident's change in condition and reassess for fall precautions.

The facility failed to reassess Resident #1 or implement fall precautions after the resident experienced six falls within less than 48 hours, indicating a failure to address a change in the resident's condition and posing a risk to resident safety.

The complaint investigation was substantiated for the allegation that staff did not answer the resident's call button in a timely manner. Other allegations regarding falls due to lack of supervision, unsafe environment, failure to assist with changing clothes, and medication dispensing were unsubstantiated or unfounded.

The investigation substantiated the allegation that staff did not respond timely to a resident's call button, citing two instances where response times exceeded 30 minutes. Other allegations including lack of supervision resulting in falls, unsafe environment, failure to assist with changing clothes, and medication dispensing were found unsubstantiated or unfounded based on records and interviews.

The complaint investigation was substantiated for the allegation that staff did not respond to resident's call for assistance in a timely manner. The allegation regarding lack of an ADA compatible room was unfounded. The allegation that staff did not meet resident's hygiene needs was unsubstantiated.

The investigation substantiated that staff did not respond to a resident's call for assistance in a timely manner, posing a potential health and safety risk. The allegation that staff did not provide an ADA compatible room was found to be unfounded. The allegation that staff did not meet the resident's hygiene needs was unsubstantiated due to lack of evidence.

The complaint investigation was substantiated for the allegation that staff did not respond timely to Resident #1's call lights. The allegations regarding the ADA compatible room and hygiene needs were found to be unfounded and unsubstantiated respectively.

The investigation substantiated that staff did not respond to Resident #1's call lights in a timely manner, posing a potential health, safety, and personal rights risk. The allegation that staff did not provide an ADA compatible room was found to be unfounded. The allegation that staff did not meet the resident's hygiene needs was unsubstantiated due to lack of sufficient evidence.

The complaint investigation was substantiated based on interviews with residents and staff, observations, and record reviews. The allegation involved physical abuse of a resident by a staff member. The preponderance of evidence standard was met confirming the abuse.

The investigation substantiated the allegation of physical abuse by Staff #1 against Resident #1. Multiple residents and staff interviews, along with observations, confirmed instances of physical abuse and rough handling by the staff member, posing an immediate health, safety, and personal rights risk to residents.

The complaint investigation was substantiated based on interviews with residents and staff, observations, and records reviewed. The allegation involved physical abuse of a resident by a staff member, which was confirmed by multiple witnesses and evidence.

The investigation substantiated the allegation of physical abuse by Staff #1 towards Resident #1. Interviews with residents and staff, along with observations, confirmed the abuse and rough handling of residents by the staff member, posing an immediate health, safety, and personal rights risk.

The complaint investigation was substantiated for the allegation that staff did not maintain a clean bathroom for Resident #1. Other allegations about unmet needs, hearing aid assistance, and safeguarding personal property were unsubstantiated.

The investigation substantiated that staff did not maintain a clean bathroom for Resident #1, posing a potential health and safety risk. Other allegations regarding unmet resident needs, assistance with hearing aids, and safeguarding personal property were unsubstantiated.

The complaint was substantiated regarding unclean bathroom floors for Resident #1, with evidence including observations and interviews confirming staff did not address urine on the bathroom floor. Other allegations about unmet resident needs, hearing aid assistance, and safeguarding personal property were unsubstantiated due to lack of preponderance of evidence.

The investigation substantiated that staff failed to maintain a clean bathroom for Resident #1, posing a potential health and safety risk. Other allegations regarding unmet needs, hearing aid assistance, and safeguarding personal property were unsubstantiated due to insufficient evidence.

The complaint was substantiated based on police reports, interviews with residents and staff, and facility observations. The alleged neglect/lack of supervision led to sexual abuse of three residents by a stranger who accessed the facility through unlocked doors.

The investigation substantiated that three residents were sexually abused by a stranger who gained entry through unlocked lobby doors. The facility failed to ensure residents were free from sexual abuse, posing an immediate health and safety risk. Multiple facility doors were found unlocked, and staff reported previous unauthorized entries.

The complaint was substantiated based on evidence that staff did not assist a resident in a timely manner after a fall on 4/24/22. The resident's pendant call was not answered for over an hour, and 911 was contacted by family members to assist. Staff were unable to answer calls due to being on a FaceTime call and unclear reasons for unanswered phone lines.

The investigation substantiated the allegation that staff failed to respond promptly to a resident's call for assistance after a fall on 4/24/22. The resident pressed their pendant call at 5:41pm but was not assisted until 911 responded nearly an hour later. Staff were unable to answer calls during this time due to phone line issues and other distractions.

The complaint was substantiated. The allegation that staff did not assist the resident from a fall in a timely manner was confirmed through record review and interviews. The resident pressed their call pendant at 5:41pm on 4/24/22, but assistance was not provided until 911 arrived at 6:35pm. Staff were unable to answer after-hours phone lines during this time.

The investigation substantiated the allegation that staff failed to assist a resident (R1) promptly after a fall on 4/24/22. The resident pressed their pendant call at 5:41pm but was not assisted until 911 responded nearly an hour later. Staff were unable to answer after-hours phone calls during this time, and the facility was cited for deficiencies related to insufficient staffing and delayed response to resident calls.

The complaint investigation was substantiated regarding failure to provide timely medical treatment to Resident #1. The facility did not seek timely medical treatment for R1, who was not evaluated until approximately 21 hours after observation of right-sided weakness and leaning to their right side, along with facial droop. The allegation regarding insufficient staffing to answer telephones was unsubstantiated.

The investigation substantiated that the facility failed to provide timely medical treatment to Resident #1 in two separate incidents, posing an immediate health and safety risk. However, the allegation regarding insufficient staffing to answer telephones was found to be unsubstantiated after review of staffing schedules and interviews.

The complaint alleged that facility staff did not provide timely medical treatment for Resident #1. The investigation found that in two incidents (03/27/21 and 07/14-15/21), the facility delayed contacting emergency medical services, resulting in Resident #1 not receiving timely medical attention until approximately 21 hours after initial symptoms. The allegation regarding insufficient staffing to answer telephones was investigated and found unsubstantiated.

The investigation substantiated that the facility failed to provide timely medical treatment to Resident #1 in two separate incidents, posing an immediate health and safety risk. However, the allegation regarding insufficient staffing to answer telephones was found to be unsubstantiated after review of staffing schedules and interviews.