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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 371881517
Report Date: 09/02/2026
Date Signed: 09/03/2026 08:36:19 AM

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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/03/2025 and conducted by Evaluator Venus Mixson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250903102337
FACILITY NAME:VISTA GARDENS MEMORY CAREFACILITY NUMBER:
371881517
ADMINISTRATOR:CAROLINE SENTENOFACILITY TYPE:
740
ADDRESS:1863 DEVON PLACETELEPHONE:
(760) 295-3900
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:99CENSUS: 95DATE:
09/02/2026
UNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:ADMINISTRATOR, CAROLINE SENTENOTIME COMPLETED:
03:08 PM
ALLEGATION(S):
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Staff neglect resulted in resident (Resident #1) sustaining multiple burns.
Staff did not seek timely medical attention for resident (Resident #1).
INVESTIGATION FINDINGS:
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On September 02, 2026, Licensing Program Analyst (LPA), Venus Mixson conducted an unannounced visit to the facility in order to deliver the findings for the above listed allegations. LPA met with Administrator, Caroline Senteno and informed them of the purpose for the visit. During the course of the investigation, interviews were conducted with staff and residents, review of documentation, and observations.

On September 3, 2025, Community Care Licensing (CCL), received a complaint alleging staff neglect resulted in resident sustaining multiple burns and staff did not seek timely medical attention for resident.

It was alleged Resident #1 (R1) sustained 2nd and 3rd degree burns due to being left unattended outside in the sun. Facility staff interviews revealed R1 was left outside in the sun by a caregiver. On 08/30/2025, at approximately 8:30 AM, a caregiver was supervising R1 on the patio. Interviews revealed the caregiver left on a break and advised two other caregivers that R1 was outsider was then left for approximately an hour and thirty minutes in the direct sunlight and there was no information obtained that a caregiver supervised R1 during that time. Staff interviews revealed that staff reviewed a copy of the facility’s surveillance footage and they reported seeing a caregiver transporting R1 to the patio and leaving R1 on the patio at approximately 10:17am. Then the footage shows the same caregiver returning at approximately 11:14am. The Department was not provided a copy of the surveillance footage because the Department was informed the footage had been deleted. Hospice records were obtained. The Hospice Patient Visit Record dated 08/30/2025 revealed “Pt fell asleep outside in direct sun unknown amount of time new 2nd degree burn to upper back neck 3-4 fluid blisters to upper back. R should blister open clear fluid draining.”
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
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 4
Control Number 18-AS-20250903102337
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
RIVERSIDE, CA 92507
FACILITY NAME: VISTA GARDENS MEMORY CARE
FACILITY NUMBER: 371881517
VISIT DATE: 09/02/2026
NARRATIVE
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 It was also alleged R1 was put back in bed without medical attention after they were found outside. Information obtained from facility staff confirmed R1 was not transported to the hospital. It was stated that on 08/30/2025, the hospice agency was contacted by facility staff and they conducted a visit to evaluate R1’s injuries. Staff interviews revealed that hospice staff advised R1 needed to be transported to be further evaluated. Facility staff reported to the Department that an additional party was contacted and this additional party refused to allow the further evaluation.

An interview with R1 was attempted, but no information was able to be obtained due to their cognitive ability. Interviews conducted with the additional party revealed they did decline further evaluation however, this additional party reported that this decision based on being advised that R1 sustained a sunburn and there were no concerns. They also reported that the severity of the injury was not communicated to them.

Based on information obtained, the allegations that staff neglect resulted in resident sustaining multiple burns and staff did not seek timely medical attention for resident have met the preponderance of evidence standard. Therefore, the above allegations are found to be SUBSTANTIATED. An Immediate Civil Penalty of $500 is being assessed today. In accordance with H&S Code Section 1569.49(e), the determination of additional civil penalties for a violation that resulted in a serious injury to the resident, is pending and under review by the Department.

An exit interview was conducted where this report, LIC9099D, LIC421IM, LIC 811, and appeal rights were discussed and provided to Administrator, Caroline Senteno.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 18-AS-20250903102337
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
RIVERSIDE, CA 92507

FACILITY NAME: VISTA GARDENS MEMORY CARE
FACILITY NUMBER: 371881517
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2026
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement is not met as evidenced by:
Based on interviews and record reviews, R1 sustained 2nd and 3rd degree burns. R1 was left unattended, outside in the sun, which posed an immediate Health & Safety risk.
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Llicensee has agreed to provide training on "Safety Check & Communication." Proof of training to be provided to the Licensing Agency by due date.

*This is an amended version of an original 9099-D issued on 09/02/2026
Type A
09/04/2026
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The plan should encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Licensee provided training to staff on Supervision of Residents in Extreme Weather Conitions. Proof of training was provided to the Licensing Agency.
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This requirement is not met as evidenced by:
Based on interviews, facility staff did not seek medical treatment for R1’s burns and blisters, despite hospice staff advising them to seek further evaluation, which posed an immediate Health & Safety risk.
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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: Reyna Lacey
LICENSING EVALUATOR NAME: Jazmond D Harris
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/03/2025 and conducted by Evaluator Venus Mixson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20250903102337

FACILITY NAME:VISTA GARDENS MEMORY CAREFACILITY NUMBER:
371881517
ADMINISTRATOR:CAROLINE SENTENOFACILITY TYPE:
740
ADDRESS:1863 DEVON PLACETELEPHONE:
(760) 295-3900
CITY:VISTASTATE:CAZIP CODE:
92084
CAPACITY:99CENSUS: 95DATE:
09/02/2026
UNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:ADMINISTRATOR, CAROLINE SENTENOTIME COMPLETED:
03:08 PM
ALLEGATION(S):
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Staff handled residents in a physically inappropriate manner.
Staff spoke to residents in an inappropriate manner.
INVESTIGATION FINDINGS:
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On September 02, 2026, Licensing Program Analyst (LPA), Venus Mixson conducted an unannounced visit to the facility in order to deliver the findings for the above listed allegations. LPA met with Administrator, Caroline Senteno and informed them of the purpose for the visit. During the course of the investigation, interviews were conducted with staff and residents, review of documentation, and observations.

On September 3, 2025, Community Care Licensing (CCL), received a complaint alleging staff Staff handled residents in a physically inappropriate manner, and Staff spoke to residents in an inappropriate manner.
It was alleged on 08/31/2025 during the morning shift with Resident #2 (R2) that during transferring from bed to wheel chair that staff #1 (S1), grabbed R2's right pointer finger and bent it back. Information obtained from interviews with staff indicated that they were not aware of and did not observe an incident of this matter. Information obtained from interviews with residents did not reveal any challenges or concerns with how the staff assist the residents with their daily activities, and there were no concerns stated with how the residents speak with the residents. A review of the records did not confirm that any concerns or injures involving R2 covering the time frame of the listed allegation.
Based on interviews record reviews and observations the information obtained was regarding the allegations
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2026
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 4