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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603664
Report Date: 09/30/2022
Date Signed: 09/30/2022 03:18:10 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2020 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20200429114447
FACILITY NAME:VISTA DEL LAGO MEMORY CAREFACILITY NUMBER:
374603664
ADMINISTRATOR:JEFF GONZALEZFACILITY TYPE:
740
ADDRESS:1817 AVENIDA DEL DIABLOTELEPHONE:
(760) 741-2888
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:0CENSUS: 0DATE:
09/30/2022
UNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:TIME COMPLETED:
02:17 PM
ALLEGATION(S):
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Licensee failed to safeguard resident's personal items
INVESTIGATION FINDINGS:
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Due to this being a closed facility, Licensing Program Analyst (LPA), Sabel Martinez, attempted to contact the license to deliver findings.The Department’s investigation consisted of review of records, and interviews with internal and external sources.

It was alleged licensee failed to safeguard resident’s personal items. Review of records obtained from an outside source revealed facility management was made aware of the missing items, at the time of the resident’s discharge from the facility. This outside source requested follow up call, but never received any type of follow up. Interviews with internal sources corroborated facility management staff in charge of reviewing inventories and addressing missing items was aware the resident’s responsible party had reported items were missing, but did not follow up as this staff waited for further clarification from the facility’s Executive Director. This corroborated facility management did not follow the facility protocol on how to address resident missing items. (See attached LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
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 6
Control Number 08-AS-20200429114447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: VISTA DEL LAGO MEMORY CARE
FACILITY NUMBER: 374603664
VISIT DATE: 09/30/2022
NARRATIVE
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Based on records reviewed and interviews with internal and external sources, the preponderance of evidence standard was met to Substantiate the above allegation. This deficiency was cited in an LIC 809D. A copy of this report, the LIC 809D and Licensee rights were mailed to the licensee via certified mail.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20200429114447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: VISTA DEL LAGO MEMORY CARE
FACILITY NUMBER: 374603664
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited
CCR
87218(a)(2)
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8712 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. (2) A licensee who fails to make reasonable efforts to safeguard resident property, shall reimburse a resident for or replace stolen or lost resident property at its current value. The licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in Section 1569.153.This requirement was not met as evidenced by:
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This POC is completed as facility is now closed.
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Based on interviews, and records reviewed, the licensee did not make reasonable efforts to safeguard resident property which posed a potential personal rights risk to one person 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: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2020 and conducted by Evaluator Sabel Martinez
COMPLAINT CONTROL NUMBER: 08-AS-20200429114447

FACILITY NAME:VISTA DEL LAGO MEMORY CAREFACILITY NUMBER:
374603664
ADMINISTRATOR:JEFF GONZALEZFACILITY TYPE:
740
ADDRESS:1817 AVENIDA DEL DIABLOTELEPHONE:
(760) 741-2888
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:0CENSUS: 0DATE:
09/30/2022
UNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:TIME COMPLETED:
02:17 PM
ALLEGATION(S):
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Staff neglect resulted in resident sustaining unexplained injuries
Licensee failed to address resident's change of condition
Licensee failed to follow reporting requirements
Licensee failed to follow the admission agreement
INVESTIGATION FINDINGS:
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Due to this being a closed facility, Licensing Program Analyst (LPA), Sabel Martinez, is mailing this report via certified mail.

The Department’s investigation consisted of review of records, and interviews with internal and external sources.

It was alleged staff neglect resulted in resident sustaining unexplained injuries. On 4/17/2020, Resident # 1 (R1) was visited by an outside source who requested R1 be transported to the hospital. An internal source informed the outside source R1 was not doing well, and the outside source witnessed R1 to be lethargic, confused and have discolored skin. R1 was transported and evaluated at the hospital. Obtained hospital documents for R1’s examination on 4/17/2020, revealed R1 had new back compression fractures.
(See attached LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
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 6
Control Number 08-AS-20200429114447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: VISTA DEL LAGO MEMORY CARE
FACILITY NUMBER: 374603664
VISIT DATE: 09/30/2022
NARRATIVE
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An interview with an additional outside source confirmed R1 had degenerative back issues, and the new compression fractures could have occurred while transferring from bed to wheelchair, turning in bed wrong, or sitting hard on a wheelchair. The injuries did not necessarily have to be caused by a traumatic injury such as a fall. No signs of trauma, nor bruising were discovered during the medical assessment that indicated R1 sustained a fall, or other accidents. R1 was not dehydrated, and fluid levels were determined to be high for a patient suffering from kidney disease, as R1 was. R1 also presented low levels of potassium, chloride, and sodium which is common for a patient suffering from liver disease. Additionally, during the assessment, R1 was not compacted, but it was discovered R1 was not having regular bowel movements which caused increased confusion. R1 was provided medication to increase bowel movement and this alleviated some of R1’s confusion. Physician’s Report with an examination date of 12/16/19, corroborated R1 suffered from confusion and disorientation. Additional obtained medical records and interviews with internal sources were consistent in corroborating R1 was not witnessed to have any falls, or any other accidents while at the facility.

It was alleged Licensee failed to address resident’s change of condition. Interviews with internal sources revealed R1 was able to communicate R1’s needs, and often required minimal, to no assistance when transferring. R1 was rarely witnessed to have complaints of pain and records obtained corroborated R1 suffered chronic back pain as a results of previous back injuries. R1 did not require toileting assistance and was able to use the restroom regularly. R1 did not communicate any concerns regarding constipation. On 4/17/2020, R1 acknowledged staff, but refused to get out of bed, ate breakfast in bed, and then showered. It was common for R1 to often sleep in as R1 would stay up late conversating with a peer. On 4/1/2022, the outside source visited R1, witnessed R1 to be pale, and requested for R1’s vitals to be checked. On 4/10/2020, the reporting party was advised R1 vitals were checked and blood work was completed. On 4/16/2020, facility staff emailed R1’s lab results to the reporting party and R1’s primary care hospital, requesting recommendations. The lab results indicated low levels of sodium, potassium, and chloride. An outside source corroborated this to be common for a patient with R1’s diagnosis, liver disease.

It was alleged licensee failed to follow reporting requirements. Interviews with Internal sources revealed R1 did not show symptoms, nor displayed any signs indicative of a change of condition. R1 was not witnessed to have any falls at the facility.

An Interview with an external source corroborated R1’s lab work results were not uncommon for someone with R1’s diagnosis. Additionally, R1 medical assessment did not reveal any signs of trauma, nor any bruises.

(See attached LIC 9099C)

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20200429114447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: VISTA DEL LAGO MEMORY CARE
FACILITY NUMBER: 374603664
VISIT DATE: 09/30/2022
NARRATIVE
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It was alleged the Licensee failed to follow the admission agreement. An outside source alleged the facility did not refund a 40 percent amount of the preadmission fee, as indicated in the admission agreement. Review of the admission agreement, the itemized ledger obtained from this outside source, and documents indicating the date of service termination, revealed the outstanding amount owed by the responsible party to the facility to be accurate. The refundable pre-admission fee amount ($1,600) was credited to the resident’s account and subtracted from a pro-rated amount ($3,336.27) based on the date the responsible party submitted a request to terminate services. There was no evidence indicating additional fees were owed to the resident, nor the resident’s responsible party.

Based on the evidence obtained through observations, review of records, and interviews with internal and external sources, there was not a preponderance of evidence to prove the violations occurred, therefore, the allegations are unsubstantiated.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 380-3797
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 755-7595
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6