374603664-7-19-2021-08-AS-DPOL-C5FNWM-20210731104947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603664
Report Date: 02/19/2021
Date Signed: 07/19/2021 02:39:55 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/20/2020 and conducted by Evaluator Evangelica Torres

COMPLAINT CONTROL NUMBER: 08-AS-20200820125835

FACILITY NAME:	VISTA DEL LAGO MEMORY CARE		FACILITY NUMBER:	374603664
ADMINISTRATOR:	JEFF GONZALEZ		FACILITY TYPE:	740
ADDRESS:	1817 AVENIDA DEL DIABLO		TELEPHONE:	(760) 741-2888
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92029
CAPACITY:	0	CENSUS: 85	DATE:	02/19/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Resident Service Director, Levina Dubose		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Facility staff violated R1's personal rights

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Eva Torres conducted a visit to deliver findings on the above allegation. LPA identified herself, spoke with Resident Service Director (RSD), Levina Dubose, and disclosed the purpose of the phone call. The investigation included interviews and a review of records.

It was alleged that staff violated Resident #1’s (R1) (See LIC 811- Confidential Names List for R1) personal rights by placing R1 on the floor.

On June 24, 2020, R1 was admitted to the facility with hospice services. A review of R1’s hospice records revealed that R1 had a neurodegenerative disorder with behavioral disturbance. According to R1’s physician’s report dated June 11, 2020, R1 required assistance with toileting, behavior support due to confusion, bathing, dressing, grooming, feeding, and medication management. Based on the facility’s Service Plan dated June 24, 2020, the licensee provided routine behavior support, fall monitoring, safety checks, and assistance with all activities of daily living.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica Torres	TELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

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 08-AS-20200820125835

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: VISTA DEL LAGO MEMORY CARE	FACILITY NUMBER: 374603664
	VISIT DATE: 02/19/2021

NARRATIVE

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On or about July 10, 2020, Staff #1 (S1) was assigned to supervise R1 at the Bistro, when R1 began to display aggressive non-compliant behavior. S1 immediately notified S2 of the incident. S2 responded and verbally attempted to de-escalate the behavior when R1 slipped underneath the table.

As S1 and S2 assisted R1 from under the table, R1 hit their head on the table, as they persisted to lunge themselves onto the floor. As a result, S2 attempted to administer PRN medication to assist with appeasing R1’s behavior. However, R1’s actions continued to intensify, as they violently struggled to thrust themselves onto the ground.

Due to the increase in behavior, S2 notified R1’s hospice agency and requested their assistance. As hospice was unable to respond timely, S2 called 911 while they simultaneously guided R1 onto the floor with them and placed their head on their lap to calm the aggression. Upon the emergency team's arrival, S2 informed them of the incident and R1’s head injury. R1 was transported to the hospital and returned to the facility on July 11, 2020, with orders to follow up with hospice. On July 11, 2020, hospice adjusted R1’s prescriptions, as well as prescribed new routine medication.

Moreover, interviews with staff and resident’s responsible parties did not support the allegation, as their statements did not revealed a history of inimical conduct by staff towards residents in care. LPA was unable to interview R1, as they passed away shortly after the incident with a cause of death being their primary medical diagnosis.

Based on interviews conducted and a review of documents, there is insufficient evidence to prove or disprove that the allegation occurred. Therefore, the complaint investigation findings are found to be unsubstantiated. An exit interview was conducted with RSD Dubose, and the Licensee’s Rights (LIC9058 01/16) along with a copy of this report was emailed to the RSD. A reply email or return receipt from the RSD will confirm receipt of documents. This is an amended version of the report that was created on 02/19/21.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica Torres	TELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

LIC9099 (FAS) - (06/04)

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