<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604065
Report Date: 09/08/2023
Date Signed: 09/08/2023 12:32:58 PM


Document Has Been Signed on 09/08/2023 12:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:LAGUNA ESTATES SENIOR LIVINGFACILITY NUMBER:
374604065
ADMINISTRATOR:WESLEY LAVENDERFACILITY TYPE:
740
ADDRESS:1088 LAGUNA DRIVETELEPHONE:
(760) 434-7116
CITY:CARLSBADSTATE: CAZIP CODE:
92008
CAPACITY:214CENSUS: 109DATE:
09/08/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director Wesley LavenderTIME COMPLETED:
12:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced case management visit to follow up on a Death Report (LIC624A) received by the Regional Office. LPA was greeted by, identified herself to, and explained the purpose of the visit to Executive Director Wesley Lavender.

On 8/23/2023, Resident 1 (R1) notified facility staff that R1 had fallen and been injured. [Executive Director was provided with a copy of the LIC811 Confidential Names List to identify R1] Facility staff assessed R1 and called for emergency services. R1 was transported to the hospital and was pronounced deceased on 8/24/2023. The facility submitted the Death Report (LIC624A) for R1 to the Department on 9/7/2023.

During the visit, LPA observed residents in care, reviewed and obtained copies of facility records, and interviewed the Executive Director. No immediate health or safety concerns were observed during the visit. Interviews with the Executive Director and review of reports received by the Department revealed that the facility did not submit an Incident Report (LIC624) for R1's fall on 8/23/2023.

The following deficiency is cited per CA Code of Regulations Title 22 and noted on the attached LIC809-D page.

An exit interview was conducted with Executive Director Wesley Lavender, whose signature below confirms receipt of a copy of this report, the LIC811, and the Licensee Rights (LIC 9058 01/16).
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/08/2023 12:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: LAGUNA ESTATES SENIOR LIVING
FACILITY NUMBER: 374604065

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2023
Section Cited
CCR
87211(a)(1)

1
2
3
4
5
6
7
87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence... This requirement has not been met as evidenced by:
1
2
3
4
5
6
7
Executive Director stated he will submit an incident report for R1's fall and will submit a written statement stated that he has reviewed reporting requirements to the Department by the POC due date of 9/15/2023.
8
9
10
11
12
13
14
Based on interviews and records review, the Licensee did not submit an incident report to the Department regarding R1's fall. This poses an potential safety risk to 109 of 109 residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A RuizTELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2