374604176-1-18-2023-08-AS-LTEZ-CNMB24-20230131234056

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604176
Report Date: 01/18/2023
Date Signed: 01/18/2023 10:00:36 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, 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 Rebecca A Ruiz

COMPLAINT CONTROL NUMBER: 08-AS-20200429123003

FACILITY NAME:	ALTA VISTA SENIOR LIVING		FACILITY NUMBER:	374604176
ADMINISTRATOR:	ALSPACH, DAVID		FACILITY TYPE:	740
ADDRESS:	2041 W VISTA WAY		TELEPHONE:	(760) 941-3233
CITY:	VISTA	STATE: CA	ZIP CODE:	92083
CAPACITY:	98	CENSUS: 71	DATE:	01/18/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Executive Director Diane Domingo		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Lack of supervision resulting in resident sustaining injury from fall
Licensee did not meet residents' care needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rebecca Ruiz conducted an unannounced complaint investigation visit to deliver findings regarding the above-mentioned allegations. LPA identified herself to, was greeted by, and explained the purpose of the visit to Executive Director Diane Domingo.

The Department’s investigation consisted of interviews with staff, and outside sources, records review, and a tour of the facility. It was alleged that lack of supervision resulting in resident sustaining injury from a fall and not meeting resident’s incontinence care needs. Review of resident 1’s (R1) medical records revealed R1 had a mild cognitive impairment, had wandering behaviors, and needed assistance with incontinence care. R1’s needs and services plan identified R1 as a fall risk. Review of an incident report submitted to the Department revealed that in April 2020, caregivers found R1 on the floor resulting in a head injury and was transferred to the hospital for treatment.
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: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

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-20200429123003

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: ALTA VISTA SENIOR LIVING	FACILITY NUMBER: 374604176
	VISIT DATE: 01/18/2023

NARRATIVE

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Review of resident 2’s (R2) medical records revealed R2 had a diagnosis of dementia and falls, had wandering behaviors, and required assistance with grooming, dressing, bathing, and incontinence care. Review of an incident report submitted to the Department revealed that in March 2020, R2 got up from their wheelchair and lost balance, fell, and sustained an injury. R2 was transferred to the hospital for treatment. Review of resident 3’s (R3) medical records revealed that R3 had a diagnosis of dementia, had wandering behaviors, and required assistance with incontinence needs. Interviews with caregivers revealed that staff knew that R3 had wandering behavior and would sometimes have incontinence accidents while wandering. Staff would attempt to redirect R3 to use the restroom but R3 would get agitated when redirected. Records review of all three residents’ needs and services plans revealed that staff were instructed to keep residents 1, 2, and 3, in common areas during the day to maximize staff supervision during the day. Interviews with staff revealed that staff tried to keep residents in memory care in common areas to remain under staff supervision and staff increased checks on residents that had been identified as fall risks. Staff would check on residents that required assistance with incontinence care and were fall risks every 2 hours. Staff on the overnight shift would assist residents with incontinence care needs at approximately 11pm and 4am. Review of the staffing schedule revealed that between two and four caregivers and one to two medication technicians were scheduled per shift in the memory care. Interviews revealed that memory care staff were able to contact staff assigned to the assisted living if they needed extra assistance. Interviews did not reveal that there were any issues with staffing and that the number of scheduled staff were able to meet the needs of residents, including R1, R2, and R3.

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

An exit interview was conducted with Executive Director Diane Domingo, to whom a copy of this report and the Licensee Appeal Rights (LIC9058 01/16) were provided via hard copy.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Rebecca A Ruiz	TELEPHONE: (619) 318-7620
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2023

LIC9099 (FAS) - (06/04)

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