Bella Villaggio.

Staff did not address a resident's toileting needs while in care/Resident was left soiled while in care. Regarding the allegation, it was reported that on or around April 11, 2021, Resident 1 (R1) was observed sitting on their own feces, and feces were also observed in R1's bathroom and on the recliner. It was reported that on or around May 4, 2020, feces were observed smeared on R1's toilet seat. During the investigation on 11/23/25, LPA interviewed the Business Manager (BM) and three (3) staff members (S1-S3), none of whom could confirm the allegation. LPA also interviewed ten (10) residents (R2-R11), none of whom could corroborate the allegation or report any complaints or concerns about their toileting needs not being met. In addition to these interviews, LPA conducted a physical plant inspection of randomly selected resident rooms and common areas. During this inspection, LPA did not detect any fecal or urine odor throughout the physical plant. Moreover, during resident interviews, LPA observed that these residents were appropriately cared for. Based on the information obtained, there was insufficient evidence to prove that staff do not address a resident's toileting needs while in care or a resident being left soiled while in care. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. Report Continued on LIC9099C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Resident sustained an injury from a fall while in care: Regarding the allegation, it was reported that on or around April 21, 2021, R1 fell at about 6:30 p.m. while attempting to go to the bathroom. R1 was transported to the hospital and placed in the ICU for four days due to a traumatic brain injury. It’s reported that the facility has no call buttons for elderly residents and those with limited mobility to get help. During the investigation on 11/23/25, LPA interviewed the Business Manager (BM) and three (3) staff members (S1-S3), who could not confirm the allegation because they either did not know who R1 is or were not working at the facility at the time of the incident on or around April 21, 2021. On 11/23/25, LPA also interviewed ten (10) residents (R2-R11). The interviews revealed that not all ten residents knew who R1 is. The LPA interviewed the Administrator and requested a copy of the Incident Report (IR) for R1’s fall on April 21, 2021. The administrator stated that, because the incident occurred almost 5 years earlier, the IR could not be located or obtained. The LPA toured the facility and visited rooms 111 and 201. The LPA pulled the call buttons in each resident room, and staff arrived within 1 to 2 minutes. Based on the information obtained, the allegation of R1 sustaining an injury from a fall while in care cannot be confirmed. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Resident was charged for services not received: Regarding the allegation, it was reported that the additional pay charged for R1 for additional care and supervision, including physical assistance with toileting, was not met. During the investigation on 11/23/25, LPA conducted interviews with the Business Manager (BM) and three (3) staff members (S1-S3), who could not confirm the allegation because staff either did not know who R1 was or were not working at the facility when the resident lived there. In addition to interviewing staff, LPA interviewed ten (10) residents (R2-R1), all of whom did not report any complaints or concerns about their needs not being met. The LPA review of R1’s medical assessment indicates that R1 requires assistance with bathing and toileting. However, the review of R1’s Admission Agreement does not confirm that R1 was paying additional charges for physical assistance with toileting, as this section of the Admission Agreement indicates no arrangements were made to pay for additional services. Only the agreed-upon basic services were included. Furthermore, R1’s Admission Agreement indicates a Level 1 level of care, and on page 32 of the Admission Agreement dated December 12, 2018, R1 declined the additional service. Report Continued on LIC9099C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Based on the information obtained, it could not be proven that a resident was charged for services not received. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation (s) did or did not occur, therefore the allegation is unsubstantiated . No deficiencies were cited. An exit interview was conducted. A copy of this report was provided to the Administrator Eloiza Castellanos.

ED stated they questioned the legitimacy of the request and asked for written justification. The Ombudsman responded by citing Welfare and Institutions Code §9722. ED stated they provided face sheets for five residents to the Ombudsman(OMB) representative during a prior visit and were never told about an ongoing investigation conducted by the OMB. Based on interviews and records review, the allegation mentioned above 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 Executive Director

and confirm the allegation, and to also identify any witnesses, but there was no reply. Between 9:20am to 10:20am, interviews with the BM and three (3) of three staff deny the allegation. Between 10:20am and 11:20am, interviews with ten (10) of ten residents expressed no complaints or concerns regarding of their needs not being met. Between 11:20am to 12:00pm, LPA conducted a physical plant inspection, and observed sufficient staff monitoring the floors during the visit. Based on the information obtained, there was insufficient evidence to prove that staff do not address a resident's toileting needs while in care or a resident being left soiled while in care. Therefore, the allegation is deemed Unsubstantiated at this time. Resident sustained an injury from a fall while in care: In regards to the allegation, it was reported that on or around April 21, 2021, R1 had a fall at about 6:30 in the evening attempting to go to the bathroom. R1 was transported to the hospital and was placed in ICU for four days, with a traumatic brain injury. There are no call buttons for the elderly and limited mobility residences to get help. After several attempts to contact the reporting party, LPA was unable to obtain additional information to corroborate with the allegation. Between 9:20am to 10:20am, interviews with the BM and three (3) of three staff deny the allegation. Between 10:20am and 11:20am, interviews with ten (10) of ten residents expressed no complaints or concerns regarding of their needs not being met. Based on the information obtained, there was insufficient evidence to prove the allegation of R1 sustaining an injury from a fall while in care. Therefore, the allegation is deemed Unsubstantiated at this time. Resident was charged for services not received: In regards to the allegation, it was reported that the additional pay that was charged for R1 for additional care and supervision to include physical assistance with toileting was not met. After several attempts to contact the reporting party, LPA was unable to obtain additional information to corroborate with the allegation. Between 9:20am to 10:20am, interviews with the BM and three (3) of three staff deny the allegation. Between 10:20am and 11:20am, interviews with ten (10) of ten residents expressed no complaints or concerns regarding of their needs not being met. Based on the information obtained, it could not be proven that a resident was charged for services not received. Therefore, the allegation is deemed Unsubstantiated at this time.

Based on the information obtained, it could not be proven that calls made to facility are not being answered. Therefore, the allegation is deemed Unsubstantiated at this time. Staff are not providing a safe environment for residents in care: In regards to the allegation, it was reported that due to phone calls not being answered by facility staff, there is some concern for the health and safety of the residents in care. There were no times and dates provided as to when calls being made were not answered. Prior to this investigation, LPA Cava made a call to the facility, and call was answered by facility staff. Between 9:20am to 10:20am, interviews with the BM and three (3) of three staff deny the allegation. Between 10:20am and 11:20am, interviews with ten (10) of ten residents expressed no complaints or concerns regarding phone service. Between 11:20am to 12:00pm, LPA conducted a physical plant inspection, and observed sufficient staff monitoring the floors during the visit. Based on the information obtained, there was insufficient evidence to prove that staff are not providing a safe environment for residents in care. Therefore, the allegation is deemed Unsubstantiated at this time.

Licensing Program Analyst (LPA), Debbie Palacios made an unannounced visit to the facility for the purpose of conducting a required annual inspection. LPA was greeted and granted entry to conduct the inspection. LPA met with administrator, Eloiza Castellanos and she was notified of the purpose for the visit. LPA toured the facility inside and outside with Administrator Eloiza. The LPA observed a centralized fire alarm/fire extinguisher system and operating carbon monoxide detectors throughout the facility. LPA observed multiple fire extinguishers that are charged were inspected on 04/02/2025. LPA observed passageways were clear of obstructions and there are rail bars in hallways. LPA was informed this facility does not allow the storage of firearms or ammunition. LPA observed the pool area fenced and locked. Residents in the assisted living unit of the facility have a key fob to access the pool. Residents in the memory care unit do not have access. LPA observed a full service restaurant, movie theater, library, game room, art room, pool table, gym and several lounges. Physical plant, floors, windows, and doors were observed to be clean and in good repair. Fixtures and furniture were in good repair and were present. The outdoor area was observed to have lots of shaded area for residents and was free of hazards. This facility has fenced/gated swimming pool. Cleaning chemicals are all handled by the maintenance staffs. LPA was informed that there is a team of maintenance staffs. All units are apartments with with kitchen, bathroom and bedrooms. Residents can either dine at the restaurants or receive food services from the facility. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Adequate staff are present for the supervision of residents during the visit, LPA also reviewed the staff schedule showing adequate staff coverage. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. Facility has adequate supply of linens and towels for use by the residents and were sufficient to meet the needs of the residents. LPA observed laundry rooms which had operating washers and dryers for residents use. Laundry room in the memory unit is locked at all times and only accessible to staff. LPA reviewed five (5) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Five (5) resident files were reviewed, and possessed all required paperwork. LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in a storage room and first aid kit with all required items. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Administrator Eloiza Castellanos.

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced visit for a required annual inspection. The LPA met with General Manager (GM) Eloiza Castellanos who was informed of the purpose of the visit. At the time of the visit there was (13) staff and (132) total residents present with (31) residents in the memory care unit. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following: LPA toured the facility inside and outside with GM Eloiza. The LPA observed a centralized fire alarm/fire extinguisher system and operating carbon monoxide detectors throughout the facility. LPA observed multiple fire extinguishers that are charged and inspected in June 2023. LPA observed hot water temperature at 113 degrees F and observed grab bars and nonskid strips where needed. LPA observed passageways were clear of obstructions and there are rail bars in hallways. LPA was informed this facility does not allow the storage of firearms or ammunition. LPA observed the pool area fenced and locked. Residents in the assisted living unit of the facility have a key fob to access the pool. Residents in the memory care unit do not have access. The LPA observed the ombudsman poster, complaint poster, residents rights and resident council information posted located in both assisted living and memory care. The LPA observed the kitchen and food storage. Food is stored, covered, temped at the proper temperature and is dated. The refrigerator measured 38 degrees F and the freezer measured -15 degrees F. The LPA was informed this facility receives food shipments 3 times a week. There is a sufficient supply of perishable and non-perishable foods to meet the requirements. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA observed medications are kept locked in the medication rooms and medication carts. LPA observed the facility utilizes an eMARS for documentation of the distribution of medication. LPA observed all medications listed on MARS and all required labeling was found to be in place. Facility has adequate supply of linens and towels for use by the residents and were sufficient to meet the needs of the residents. LPA observed laundry rooms which had operating washers and dryers for residents use. Laundry room in the memory unit is locked at all times and only accessible to staff. LPA reviewed five (5) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. Five (5) resident files were reviewed, and possessed all required paperwork. LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies in a storage room and first aid kit with all required items. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to General Manager Eloiza Castellanos.

During today's visit, LPA Nickolas' requested a current copy the facility's employee roster and confirmed that the caregiver with an average response time of 32 minutes and 58 seconds, is no longer employed at this facility. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation. A finding of unsubstantiated 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, and a copy of this report was provided.

Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to gather additional information pertinent to complaint control number 18-AS-20210804114615. LPA Nickolas met with General Manager Eloiza Castellanos and explained the purpose of this visit. LPA advised Castellanos that, at this time, the complaint requires further investigation. Possible follow-up telephone calls, requests for copies of relevant documents, and visits are necessary before reaching investigative findings. No deficiencies were cited during this visit. An exit interview was conducted with Castellanos, and a copy of this report was provided.