374604065-2-23-2026-08-AS-BFOG-DRP4TC-20260226182254

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604065
Report Date: 02/23/2026
Date Signed: 02/23/2026 01:48:16 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
12/01/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 08-AS-20221201102413

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: 94	DATE:	02/23/2026
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Natalie Carlborg, Executive Director		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff left resident in a soiled diaper for an extended period of time
Staff did not respond to residents call button in a timely manner
Staff did not administer residents medication in a timely manner
Staff did not safeguard residents personal belongings
Staff are not providing adequate food service to residents
Staff did not ensure residents plugs in room are not in disrepair
Unlawful eviction

INVESTIGATION FINDINGS:

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On 02/23/26 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint investigation, explained the purpose of the Zoom meeting and delivered investigation findings to ED.

On 10/18/22, 12/01/22 and 03/01/23, LPA L Silveira conducted interviews with reporting party (RP), residents (R2, R3) and staff (ED, H1, H2) and made observations in random residents’ apartments (R1, R2, R3, R4, R5). Review of RCFE Laguna Estates Senior Living facility # 374604065 history showed a change of ownership effective 04/15/2019 to Vista Carlsbad Village Senior Living with no change in facility number. During investigation, LPA L Silveira obtained the following documents from ED: Personnel record, Residents’ roster, admission agreements, call button records, charting notes, R1 timeline of issues, eviction notice, medication records, pest control reports, resident face sheets, SOC341 and photos.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

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 4

Control Number 08-AS-20221201102413

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: LAGUNA ESTATES SENIOR LIVING	FACILITY NUMBER: 374604065
	VISIT DATE: 02/23/2026

NARRATIVE

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Allegation: Staff left resident in a soiled diaper for an extended period of time
Finding: Unsubstantiated
During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). Review of R1’s timeline of issues at the facility showed R1 engaged in inappropriate behaviors towards staff and disturbed other residents from 05/08/22 to 10/23/22. This included R1’s refusal to allow staff to change his soiled brief on the following dates – on 08/02/22 R1 refused to allow staff to change his brief stating he wanted police to change him (R1 called 911); 08/21/22 R1 refused to allow his soiled brief to be removed by staff and preferring it to be left on the floor so police could see it (R1 called 911); 09/18/22 R1 refused to allow care team to change his soiled brief and blew a whistle when he was brought to the lobby disturbing other residents. On 10/09/22 and 10/12/22, R1 refused to allow staff to change his soiled brief and clothing, was verbally abusive to staff, attempted to kick staff and called 911 stating his care needs are not being met. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation staff left resident in a soiled diaper for an extended period of time was found to be unsubstantiated.

Allegation: Staff did not respond to residents call button in a timely manner
Finding: Unsubstantiated
During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). ED stated R1 has dementia who kept his call pendant light on 24/7. Staff (PD) witnessed R1 hit/scratch care staff, used foul language towards caregivers on 07/21/22, wouldn’t allow them to reset his call pendant, swung a broom at staff on 08/23/22 and would constantly call 911 stating staff was intentionally trying to harm, poison and kill him. On 09/17/22 R1 refused care team and would not allow them to reset his call pendant. ED stated R1 would constantly call 911 stating care staff was not attending to his needs. On 09/18/22 R1 refused to allow staff to change his brief and was brought to the lobby with whistle and created disturbance. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation staff did not respond to residents call button in a timely manner was found to be unsubstantiated.

Continued on next page, LIC 9099C pg1

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 08-AS-20221201102413

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: LAGUNA ESTATES SENIOR LIVING	FACILITY NUMBER: 374604065
	VISIT DATE: 02/23/2026

NARRATIVE

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Allegation: Staff did not administer resident’s medication in a timely manner
Finding: Unsubstantiated
During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). Review of R1’s timeline of issues showed R1 engaged in inappropriate behaviors towards staff and disturbed other residents from 05/08/22 to 10/23/22. This included R1’s refusal to take his insulin medication on 07/15/22, 07/27/22 and 10/15/22 as well as constantly arguing with staff regarding his insulin dosages. On 09/24/22, R1 exited his apartment and struck care staff, accusing staff of poisoning him. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not administer resident’s medication in a timely manner was found to be unsubstantiated.

Allegation: Staff did not safeguard resident’s personal belongings
Finding: Unsubstantiated
During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). ED stated that R1 was first admitted at the facility in March 2022. ED stated R1 has dementia, paranoia and required a higher level of care. Review of R1’s documents did not show any theft or loss incident reports while R1 was in care at the facility. LPA also interviewed other residents (R2, R3) who stated that they did not have any missing items in their rooms. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not safeguard resident’s personal belongings was found to be unsubstantiated.

Allegation: Staff are not providing adequate food service to residents

Finding: Unsubstantiated
During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). ED stated R1 was first admitted at the facility in March 2022 and engaged in inappropriate behaviors towards staff and other residents from 05/08/22 until his eviction on 11/30/22. ED stated RP stated R1 wouldn’t allow the call light to be turned off, wouldn’t allow care staff to change his briefs, would argue with staff regarding his dosages of insulin, would yell racist and derogatory statements to a Black nurse, calling him “nigger”, would call 911 often, claiming he wasn’t receiving care. On 03/01/23, LPA interviewed R2 and R3 who stated they had no issues with food services at the facility. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff are not providing adequate food service to residents was found to be unsubstantiated.
Continued on next page, LIC 9099C pg2

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20221201102413

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: LAGUNA ESTATES SENIOR LIVING	FACILITY NUMBER: 374604065
	VISIT DATE: 02/23/2026

NARRATIVE

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Allegation: Staff did not ensure residents’ plugs in room are not in disrepair
Finding: Unsubstantiated
On 12/09/22, LPA L Silveira conducted a walk through with ED at the facility of the following random bedrooms – B211, B219, B213, B318). LPA did not observe any electrical cover missing in the outlets nor wires sticking out of them during the walk through. ED stated R1 or his authorized representative did not report any electrical outlet issues with management while R1 was still residing at the facility. LPA also interviewed residents (R2, R3) who stated that they did not observe any missing electrical outlet covers or exposed electrical outlet wirings inside their apartments. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not ensure residents’ plugs are not in disrepair was found to be unsubstantiated.

Allegation: Unlawful eviction
Finding: Unsubstantiated
During investigation, LPA L Silveira interviewed staff (ED, H1, H2) and residents (R2, R3). Review of R1’s timeline of issues showed R1 engaged in inappropriate behaviors towards staff and disturbed other residents from 05/08/22 to 10/23/22. ED notified R1 and RP on 06/26/22, that continued inappropriate behaviors towards staff, accusing them of intentionally harming R1 and calling 911 constantly were in violation of the facility’s rules regarding good conduct and that further incidences may result in the termination of R1’s admission agreement. On 10/13/22, R1 physically and verbally assaulted care staff in the lobby witnessed by other staff and management who called 911 and notified RP that R1 is no longer compatible at the community. On 11/01/22, ED stated they issued R1 and RP a 30-day eviction notice effective 11/30/22 for non-payment of basic services, violations of facility policies and incompatibility with other residents in care. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation of unlawful eviction was found to be unsubstantiated.

No deficiencies cited during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2026

LIC9099 (FAS) - (06/04)

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