371881458-8-28-2024-18-AS-TDAN-D8MRB5-20240830125211

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 371881458
Report Date: 07/30/2024
Date Signed: 08/28/2024 04:14:26 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/16/2024 and conducted by Evaluator Sara Martinez

COMPLAINT CONTROL NUMBER: 18-AS-20240716104536

FACILITY NAME:	VISTA ELDER CARE		FACILITY NUMBER:	371881458
ADMINISTRATOR:	SUBOTIC, NIKOLA		FACILITY TYPE:	740
ADDRESS:	1756 CLUB HEIGHTS LN		TELEPHONE:	(760) 828-7226
CITY:	VISTA	STATE: CA	ZIP CODE:	92081
CAPACITY:	6	CENSUS: 5	DATE:	07/30/2024
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Nikola Subotic - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff handled resident in a rough manner.
Staff force fed resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conclude the investigation into the allegations listed above. LPA concucted an interview with Administrator Nikola Subotic who was informed of the purpose of the call. The complaint investigation consisted of a tour of the interior/exterior areas of the facility, interviews with staff and residents, and records review of requested pertinent documents.

Regarding the allegation “Staff handled resident in a rough manner” it was reported Staff One (S1) had put their hands around Resident One's (R1) neck and attempted to strangle R1 in the early morning of 07/15/2024. R1 reported incident to a Hospice staff during a scheduled visit on 07/15/2024. Administrator Ninoka Subotic was informed of the incident and had contacted R1’s responsible party. R1 was examined by paramedics and was sent to the hospital in the afternoon on 07/15/2024. Administrator Subotic conducted an internal investigation the same day that had yielded insufficient information to corroborate the allegation and S1 was dismissed from work. *This is an Amended Report*

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20240716104536

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VISTA ELDER CARE	FACILITY NUMBER: 371881458
	VISIT DATE: 07/30/2024

NARRATIVE

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LPA conducted interviews with three (3) facility staff and (2) hospice staff who did not observe, have not observed, or have not previously heard of S1 handling R1 or the other residents in care in a rough manner. LPA conducted interviews with two (2) residents who denied being handled in a rough manner by S1 or other facility staff members. LPA conducted a records review of R1’s Physician Orders dated 06/17/2024 revealed R1 experiences confusion and/or is disoriented “sometimes”. R1’s Resident Appraisal dated 06/15/2024 states R1 “experiences episodes of confusion…”. LPA conducted an interview with R1 and determined R1 was not a reliable historian due to R1 stating the incident had occurred at a "well known hotel". S1 reported they did not handle R1 in a rough manner and had entered R1’s room multiple times throughout the night to conduct safety checks. Therefore based on interviews and records review the allegation “Staff handled resident in a rough manner” has been deemed Unsubstantiated at this time.

Regarding the allegation “Staff force fed resident” it was reported S1 had forced food into S1’s mouth. Interview with two (2) residents denied hearing or observing S1 or other facility staff force feeding R1 or other residents in care. During the initial visit LPA observed staff preparing and serving lunch to the residents that did not indicate staff force feeding residents in care. Interview with three (3) staff reported they do not force feed residents and four (4) out of five (5) residents are capable of eating on their own without assistance. S1 reported they do not push food onto R1 and R1 does not need help with eating. Administrator Subotic reported R1 does not need assistance with eating. R1’s Physician Orders dated 06/17/2024 indicated R1 is capable of feeding self. R1’s Resident Appraisal dated 06/15/24 under “Services Needed” for “Help with eating (need for adaptive devices or assistance from another person)” is marked as “No”. LPA observed R1 eating a soup and a sandwich on their own with no staff assisting R1. LPA conducted an interview with R1 and determined R1 was not a reliable historian. Therefore based on observation, interviews, and records review the allegation “Staff force fed resident” has been deemed Unsubstantiated at this time. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated.

An exit interview was conducted over the phone and a copy of this report was provided to Administrator Subotic.

*This is an Amended Report*

SUPERVISOR'S NAME: Tricia Danielson	TELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC9099 (FAS) - (06/04)

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