374604065-9-14-2023-08-AS-LTEZ-CW4V8P-20230928161304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604065
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:00:03 PM

Unsubstantiated

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
05/05/2023 and conducted by Evaluator Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20230505110747

FACILITY NAME:	LAGUNA ESTATES SENIOR LIVING		FACILITY NUMBER:	374604065
ADMINISTRATOR:	WESLEY LAVENDER		FACILITY TYPE:	740
ADDRESS:	1088 LAGUNA DRIVE		TELEPHONE:	(760) 434-7116
CITY:	CARLSBAD	STATE: CA	ZIP CODE:	92008
CAPACITY:	214	CENSUS: 110	DATE:	09/14/2023
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Assistant Health Services Director Sue Alvarez		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not administer medications as prescribed
Staff did not treat resident(s) with dignity

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint visit to conduct follow-up and deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Assistant Health Services Director Sue Alvarez. Executive Director Wesley Lavender arrived during the visit.

During today's visit, LPA observed residents in care and interviewed residents and the Executive Director.

The Department’s investigation consisted of interviews with residents, staff, and outside sources, records review, and a tour of the facility. It was alleged that staff did not administer resident’s medication as prescribed and staff did not treat resident(s) with dignity. Review of medical records revealed that Resident 1 (R1) had a mild cognitive impairment, was confused and disoriented at times, had a history of aggressive behaviors, and required assistance with medication administration.
Continued on LIC9099-C page...

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

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-20230505110747

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: LAGUNA ESTATES SENIOR LIVING	FACILITY NUMBER: 374604065
	VISIT DATE: 09/14/2023

NARRATIVE

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Review of medication records and interviews revealed that R1 received multiple medications a day and received medication management services by the facility. Review of R1’s medication administration records noted multiple instances in early May 2023 where R1 requested to take the medication at a different time than prescribed. Medication records did not reveal any instances where medications were missed or not given to R1. Interviews with staff revealed that R1 had requested that medications were given to them at a specific time and would get upset with staff if they were unable to meet that specific time period. Interviews with staff revealed that staff were able to give a medication to a resident within an hour prior to and an hour after the time a medication was ordered to be given. After that 2 hour window, the medication would be considered missed. Staff interviews revealed that if a resident refused a medication, staff would attempt to give the medication to the resident a total of 3 times before marking the medication as refused. Staff would also change the staff member giving the medication to the resident in an attempt to have the resident accept the medication from a different individual. Staff interviews revealed that staff would attempt to understand why a resident was refusing a medication and would work with the resident to decrease the likelihood of medication refusal. Interviews with staff and residents did not reveal any issues with staff assisting residents with medication administration.

Interviews with staff and R1 revealed that R1 was difficult to work with, became angry often, and had a history of yelling at staff. Interviews revealed that R1 would get upset when medications were given differently than how R1 expected medications to be given. Interviews revealed that R1 would curse and yell at staff and staff began passing medications to R1 with another staff present. Facility management also reviewed the prescribing orders with R1 and changed the staff responsible for passing medications to R1 in an effort to decrease R1’s agitation. Interviews with staff revealed that facility management was in contact with R1’s responsible party to address R1’s agitation and the responsible party was able to explain the medication orders to R1.

Continued on LIC9099-C page...

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230505110747

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: LAGUNA ESTATES SENIOR LIVING	FACILITY NUMBER: 374604065
	VISIT DATE: 09/14/2023

NARRATIVE

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Interviews with staff revealed that when staff encountered rude behaviors from residents, staff would request that residents stopped those behaviors and would remove themselves from the situation. Staff denied being rude, disrespectful, or yelling at residents, including R1. Interviews with residents did not reveal any issues with staff being rude, disrespectful, yelling, or cursing at residents.

The Department has investigated the above-mentioned allegations and based on interviews and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

An exit interview was conducted with Executive Director Wesley Lavender, whose signature below confirms receipt of a copy of this report and the Licensee Appeal Rights (LIC9058 01/16).

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023

LIC9099 (FAS) - (06/04)

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