374603664-6-15-2021-08-AS-DPOL-C5F33J-20210730175337

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603664
Report Date: 06/15/2021
Date Signed: 06/15/2021 09:18:03 AM

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
12/27/2019 and conducted by Evaluator Evangelica Torres

COMPLAINT CONTROL NUMBER: 08-AS-20191227095100

FACILITY NAME:	VISTA DEL LAGO MEMORY CARE		FACILITY NUMBER:	374603664
ADMINISTRATOR:	KELLY, CHANNA		FACILITY TYPE:	740
ADDRESS:	1817 AVENIDA DEL DIABLO		TELEPHONE:	(760) 741-2888
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92029
CAPACITY:	0	CENSUS: 84	DATE:	06/15/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Executive Director, Jeff Gonzalez		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Lack of supervision resulting in a non-consensual sexual encounter

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Eva Torres conducted a follow-up visit to deliver the investigation findings. LPA identified herself, and met with Executive Director, Jeff Gonzalez and Resident Service Director, Levina Dubose. During the meeting, LPA disclosed the purpose of the visit.

The findings rendered are based on an investigation conducted by the Department. The investigation included a review of records, as well as interviews conducted with staff and outside sources.

It was alleged that a lack of supervision resulted in a non-consensual sexual encounter between Resident #1 (R1) and Resident #2 (R2) (See LIC 811- Confidential Names List).

On October 22, 2018, R1 was admitted to the licensed facility. According to R1's physician's reports dated October 17, 2018, and September 12, 2019, R1 has a neurocognitive impairment that contributes to their confusion, along with their inappropriate and wandering behavior. R1's assessment, dated February 06. 2019 showed that R1 required every two hours safety checks and assistance in hygiene, bathing, dressing, grooming, incontinence care, and medication management.

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: 06/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

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-20191227095100

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: 06/15/2021

NARRATIVE

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R1's Plan of Care dated October 22, 2018, showed that R1 received behavior support of hourly safety checks and stand-by assistance with bathing, dressing, grooming, and medication management. On February 06, 2020, a reassessment was performed in which the facility maintained its safety checks.

On February 04, 2019, R2 was admitted to the licensed facility. According to R2's physician’s reports dated February 01, 2019, and March 06, 2019, the documents showed that R2 had a cognitive impairment with behavior disturbances that also contributed to their increase in confusion and wandering behavior. R2's assessment dated January 31, 2019, showed that R2 required assistance in the areas of hygiene, stand-by assistance with bathing and grooming, and medication management. R2's Plan of Care dated February 05, 2019, showed that R2 received behavioral support that included hourly safety checks of eight per shift.

Upon further review of the facility's records, on February 26, 2019, R2 was witnessed engaging in self-harming behavior. The facility staff de-escalated the incident as they provided R2 with verbal prompts to discontinue the self-harming behavior. At that time, R2 was transported to the hospital for further observation.

On September 25, 2019, at approximately 01:13 PM, a staff found R2 in another resident's (R3) bedroom. Staff immediately redirected R2 out of R3's bedroom. On the same day, R2 was reassessed due to the behavior change, in which the facility maintained its hourly behavioral safety checks.

On December 19, 2019, at approximately 02:43 PM, staff observed R2 pulling on their jacket string. Staff investigated the behavior and noticed that the jacket string was wrapped around R2's neck. Staff immediately redirected the behavior and removed the jacket string from R2 possession. Staff assessed R2 from head to toe and placed R2 under one on one supervision until a Geri Psych physician evaluated them.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica Torres	TELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20191227095100

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: 06/15/2021

NARRATIVE

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On December 21, 2019, at approximately 09:36 PM, staff observed R2 sitting on R1's bed, engaged in an independent sexual behavior while R1 slept. Staff verbally redirected R2 out of R1's bedroom, assessed R1, and called law enforcement. Law enforcement arrived and attempted to interview R1 and R2. However, a statement was unable to be obtained from R1 and R2 due to their cognitive impairment. As a result, law enforcement closed the investigation as they could not establish that a crime had occurred.

Moreover, evidence does not support that R1 witnessed R2’s sexual behavior. Though staff interviews had some inconsistencies in the time frames when safety checks were conducted, R2's behavior check log documented R2's location every hour on December 21, 2019, which was the day of the incident. The facility’s behavior monitoring log showed R2 was in their bedroom at 09:00 PM. Furthermore, R1's daily activity record and safety check log showed that staff frequently interacted with R1 as staff conducted their safety checks and assisted R1 with their care needs.

Based on interviews conducted and a review of documents, there is insufficient evidence to prove the allegation occurred due to lack of supervision. Therefore, the complaint investigation findings are found to be unsubstantiated. LPA conducted an exit interview with Mr. Gonzalez and Mrs. Dubose. LPA also confirmed their contact information. The Licensee's Rights (LIC9058 01/16) and a copy of this report were email to Mr. Gonzalez. Mr. Gonzalez ‘s signature on this form, along with a reply email or return receipt from him will confirm receipt of documents.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Evangelica Torres	TELEPHONE: (619) 900-1407
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

LIC9099 (FAS) - (06/04)

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