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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880835
Report Date: 07/21/2023
Date Signed: 07/27/2023 03:06:48 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2023 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230417141809
FACILITY NAME:VISTA BLUE MOUNTAINFACILITY NUMBER:
361880835
ADMINISTRATOR:ASHLEY WILLETTFACILITY TYPE:
740
ADDRESS:22325 BARTON ROADTELEPHONE:
(909) 420-0153
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:0CENSUS: 0DATE:
07/21/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Ashley Willett, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff did not administer resident's medication
Staff are mismanaging resident's medication
INVESTIGATION FINDINGS:
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This meeting is being conducted by Amy Goldenberg, Licensing Program Analyst (LPA), to conclude this agency’s investigation into the complaint allegations mentioned above. This meeting is being held at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office. LPA reviewed this report and provided a copy to the facility representative Ashley Willett, Administrator.

Investigation included review of records for R1, interview of staff and interview of witnesses. Investigation revealed the following information: R1 moved from from Vista Blue Mountain on 03/26/2023 to another assisted living facility. It is alleged that the nurse receiving R1's medications during their move in to the new facility told R1's responsible party that one of the medications (Lorstatin) was expired and they would need a new refill. Interview with the receiving nurse verified that the medication Lorstatin that R1 arrived with was expired so the facility did not receive the medication. Expired medications had been retained at Vista Blue Mountain and not properly disposed of. This practice indicated mishandling of residents medications.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 56-AS-20230417141809
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: VISTA BLUE MOUNTAIN
FACILITY NUMBER: 361880835
VISIT DATE: 07/21/2023
NARRATIVE
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 It is alleged that the facility did not administer a medication. Interview with R1's receiving nurse revealed a second resident (R2) which arrived to the facility on 3/29/2023 which was previously residing at Vista Blue Mountain. During intake of the medication for R2, a fungal medication called Terninafine was present. The medication had an order for 42 days of treatment and was initially filled on 11/7/22 for 30 tabs, and a second bottle filled on 12/1/2022 for 12 tabs. During transfer the receiving nurse was counting the medication it was revealed that all the medication was there. LPA reviewed LIC622 documenting R2's medications received. LPA calculated back and the prescription should have been completed prior to her moving out of Vista Blue Mountain. There were no notations in review of Vista Blue Mountains documentation to indicate the medication was held or the order canceled and the evidence supports that the medication was not given.

We have substantiated the complaint allegations as valid and find that a violation has occurred based on the preponderance of available evidence. A copy of this report along with appeal rights are being reviewed with, and furnished to the facility representative. Please see LIC 9099D.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20230417141809
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: VISTA BLUE MOUNTAIN
FACILITY NUMBER: 361880835
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/22/2023
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care:The licensee shall assist residents with self-administered medications as needed.The facility did not meet this requirement as evidenced by failure to provide R2
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FACILITY CLOSED
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with assistance to manage the medication Terninafine. This poses a risk to the health and safety of residents in care.
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Type A
07/21/2023
Section Cited
CCR
87465(i)
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Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident....
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FACILITY CLOSED
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The facility has not managed R1's medications properly as evidenced by retention of expired the medication Lorstatin. This poses a risk to the health nad safety of residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/17/2023 and conducted by Evaluator Amy Goldenberg
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230417141809

FACILITY NAME:VISTA BLUE MOUNTAINFACILITY NUMBER:
361880835
ADMINISTRATOR:ASHLEY WILLETTFACILITY TYPE:
740
ADDRESS:22325 BARTON ROADTELEPHONE:
(909) 420-0153
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:0CENSUS: 0DATE:
07/21/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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3
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9
Staff did not properly assess resident for change in medical condition
INVESTIGATION FINDINGS:
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This Regional Office meeting is being conducted by Amy Goldenberg, Licensing Program Analyst (LPA), to conclude this agency’s investigation into the complaint allegation mentioned above. LPA reviewed this report and provided a copy to the facility representative....

Investigation included review of records for R1, interview of staff and interview of witnesses. It is alleged that R1 had a change in their condition. Investigation revealed the following information: Interview revealed that R1 had an episode of leaving the facility. Sometime around May 2022 R1 wandered from the facility at 2AM. R1 was residing in the Assisted Living area of the facility at the time. Allegations includes that the facility had not properly assessed R1 prior to being moved to Memory Care. R1 moved to memory care on 05/13/2023.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20230417141809
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: VISTA BLUE MOUNTAIN
FACILITY NUMBER: 361880835
VISIT DATE: 07/21/2023
NARRATIVE
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 Records include Vista Blue Mountian Level of Care Assessments CA form dated 5/19/2022. Number 2 on page one of the document indicated the the assessment is being done for a change of condition. R1's responsible party is indicated on page number 4, but is not signed. LPA reviewed facility notes for May 2022. Entries made on 5/10/22 at 1:57PM, 5/10/2022 at 2:14PM, 5/13/2022 at 12:33PM, note family communication regarding change of condition. The available information received through review of records, and interviews is not sufficient enough to confirm or refute that the facility had not addressed R1's change in condition.

We have found the complaint allegation is unsubstantiated, although the allegation may have happened or is valid: there is not a preponderance of the evidence to prove that the alleged violation occurred. A copy of this report is being reviewed with and furnished to the facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amy GoldenbergTELEPHONE: (951) 201-3990
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5