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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604176
Report Date: 04/18/2025
Date Signed: 04/20/2025 05:00:25 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/30/2022 and conducted by Evaluator Venus Mixson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20221130130504
FACILITY NAME:ALTA VISTA SENIOR LIVINGFACILITY NUMBER:
374604176
ADMINISTRATOR:ALSPACH, DAVIDFACILITY TYPE:
740
ADDRESS:2041 W VISTA WAYTELEPHONE:
(760) 941-3233
CITY:VISTASTATE: CAZIP CODE:
92083
CAPACITY:98CENSUS: 81DATE:
04/18/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:EXECUTIVE DIRECTOR, JENNIFER GEPHARTTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Neglect / Lack of Care and Supervision
Resident's wound has not recovered due to staff neglect
Staff do not ensure that resident's dietary needs are met
Insufficient staffing to meet the needs of residents in care
Staff did not keep the resident's room free from odor
Staff did not keep resident's room clean
Staff did not safeguard resident's personal items
INVESTIGATION FINDINGS:
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On April 18, 2025, Licensing Program Analyst (LPA), Venus Mixson arrived at the facility unannounced and met with Executive Director, Jennifer Gephart.
LPA explained the reason for the visit was to provide findings for the complaint investigation.

On November 30, 2022, Community Care Licensing received a complaint alleging Neglect / Lack of Care and Supervision, resident's wound has not recovered due to staff neglect, staff do not ensure that resident's dietary needs are met, insufficient staffing to meet the needs of residents in care, staff did not keep the resident's room free from odor, staff did not keep resident's room clean, staff did not safeguard resident's personal items. During the investigation LPA’s conducted interviews, record reviews, and made observations.

Regarding the allegation that Neglect/Lack of Care and Supervision it was reported that Resident Number 1 (R1) had an unwitnessed fall and was sent to the Emergency Room (ER) at Tri-City Medical Center. Information obtained from interview with attending physician Dr. Bonomo advised that a Cat Scan (computed axial tomography) (CT) did not reveal any head injuries only a minor laceration to R1’s ear lobe.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
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 5
Control Number 18-AS-20221130130504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ALTA VISTA SENIOR LIVING
FACILITY NUMBER: 374604176
VISIT DATE: 04/18/2025
NARRATIVE
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Regarding the allegation staff do not ensure that resident's dietary needs are met, it was reported that staff put food in front of the residents and leave them slumped over alone to eat. It was stated that R1 required assistance with eating. It was further reported that R1 has lost a significant amount of weight (approximately 30 to 50 lbs.) since being placed at the facility. Information obtained from interviews with facility staff advised that R1 does eat well balanced meals and can feed themselves. It was advised that R1 may need assistance with certain foods, but there are no documented plans regarding eating assistance in R1’s service plan. Interviews with additional residents indicated that there were no noted concerns with ensuring their dietary needs were met, they do not have any concerns regarding dietary needs being met to at this time. A review of the records confirmed R1 is able to eat with her hands but may require assistance if utensils are needed. Additional information obtained from observations revealed that R1 was able to eat without assistance. A review of the records did not corroborate that any significant amount of weight was lost the information obtained from a review of R1’s weight records confirmed a loss of six pounds from the time of admissions to discharge date on 05/21/2023.
Regarding the allegation the facility has insufficient staffing to meet the needs of residents in care, it was reported that staffing has been a consistent issue and the reason that most of R1’s needs do not get met. Information obtained from interviews with Administrator, Jennifer Gephart advised that the facility guidelines for staff meeting the needs of residents in care is to follow the resident’s plan of care upon admissions and to conduct an assessment. Interviews with additional staff indicated that R1 was receiving Hospice services and nurses were at the facility two to three times a week to attend to the needs of R1. A review of the records confirmed that R1 was receiving services through Cabrillo Hospice agency; narrative charting, nurses sign in sheets, and other documents were obtained. Interviews with additional staff indicated that the care staff are continuously training on personal rights care and supervision, and that staff are scheduled per each shirt to provide adequate care and supervision. Additionally, residents are encouraged to visit their primary physicians annually. Documents provided and reviewed on site to confirm this. Addition interview with administrator, Jennifer indicted that staff are continuously receiving training on personal rights, and the care and supervision of residents in care. Interviews with additional residents indicated that there are sufficient staff to meet their needs, and that there are all ways enough staff from the Med-tech to the nurses. The nurses are usually moving about there were no reported concerns. Information obtained from records reviewed included staff schedules and confirm adequate staff are scheduled per shift. No noted concerns document currently.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20221130130504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ALTA VISTA SENIOR LIVING
FACILITY NUMBER: 374604176
VISIT DATE: 04/18/2025
NARRATIVE
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Regarding the allegation staff did not keep the resident's room clean and free from odor it was reported that R1’s room had an unpleasant smell, the baseboards were covered with a sticky brown substance, and that R1’s room had piles of dirty laundry. Information obtained from interview with Administrator advised that the facilities policy on housekeeping and how the residents’ rooms are maintained is that the house keeping is scheduled daily from 6:00am to 6:00pm. There are three house keepers, and each work daily or as needed. A review of the house keeping scheduled corroborated the information. Interviews with additional staff indicated that housekeeping and how the residents’ rooms are maintained is through the housekeeping team. Information obtained from interviews with additional staff indicated that caregivers inform the housekeeper staff if there is an additional need and they will clean it. Additional information stated that caregivers do not usually clean the residents’ rooms that is what the housekeepers are for. Interview with R1 was not possible currently. Interviews with additional residents indicated they are happy with the housekeeping and how their rooms are maintained. Additional information obtained from resident interviews stated that there are no noted concerns with how their rooms are kept clean.

Regarding the allegation staff did not safeguard resident's personal items, it was reported that another resident was observed coming in and out of R1’s room without permission. Information obtained from interviews with facility staff advised that facility’s policy on safeguarding personal property that the residents are responsible for the safeguarding of their own personal items and property. Interviews with additional staff indicated that the facility encourages residents not to have anything of value, if so, there are lock boxes in the respective living units. Observations confirmed facility had security cameras in place, safety lock boxes if requested in living units, and doors can be locked. Interviews with additional staff stated that each resident living unit has a lock on the door and each room is equipped with a lockbox if requested. Interviews with additional residents indicated that there were no noted concerns with the safeguarding of their personal items.

Based on LPA's inability to interview pertinent parties, interviews, record reviews, and observations there is not enough information to support the listed allegations. Therefore, these allegations have been determined unsubstantiated. An allegation finding of unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violations did or did not occur. An exit interview was conducted, and a copy of this report was provided to Executive Director, Jennifer Gephart.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20221130130504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ALTA VISTA SENIOR LIVING
FACILITY NUMBER: 374604176
VISIT DATE: 04/18/2025
NARRATIVE
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Regarding the allegation staff did not keep the resident's room clean and free from odor it was reported that R1’s room had an unpleasant smell, the baseboards were covered with a sticky brown substance, and that R1’s room had piles of dirty laundry. Information obtained from interview with Administrator advised that the facilities policy on housekeeping and how the residents’ rooms are maintained is that the house keeping is scheduled daily from 6:00am to 6:00pm. There are three house keepers, and each work daily or as needed. A review of the house keeping scheduled corroborated the information. Interviews with additional staff stated that housekeeping and how the residents’ rooms are maintained is through the housekeeping team. Additional information obtained stated that caregivers advise the housekeeping staff if there is an additional need and they will clean it. Additional information stated that caregivers do not usually clean the residents’ rooms that is what the housekeepers are for. Interviews with additional residents indicated that they are happy with the housekeeping and how the residents’ rooms are maintained. Additional information obtained from resident interviews stated that there are no noted concerns with how their rooms are kept clean.

Regarding the allegation staff did not safeguard resident's personal items, it was reported that another resident was observed coming in and out of R1’s room without permission. Information obtained from interviews with facility staff advised that facility’s policy on safeguarding personal property that the residents are responsible for the safeguarding of their own personal items and property. The facility encourages residents not to have anything of value, if so, they have a lock box in the respective living units. Observations confirmed facility had security cameras in place, safety lock boxes if requested in living units, and doors can be locked. Interviews with additional staff stated that each resident living unit has a lock on the door and each room is equipped with a lockbox if requested. Interviews with additional residents indicated that there were no noted concerns with the safeguarding of their personal items.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20221130130504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: ALTA VISTA SENIOR LIVING
FACILITY NUMBER: 374604176
VISIT DATE: 04/18/2025
NARRATIVE
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Additional information obtained from interviews with Executive Director Diane Domingo advised that a conference call with R1’s family, and the family agreed to the service plan. Information obtained from interviews with the Hospice Nurse advised that R1 had behavioral problems and is easily agitated and that the Hospice Nurses maintain a record of R1’s progress and treatment of overall health. Further information obtained from observations revealed that R1 appeared to look well and was well cared for. Information obtained does not support the allegation.
Regarding the allegation Resident's wound has not recovered due to staff neglect, it was reported that R1 has a wound located on their hip. It was reported that the wound has not healed in over one year. Information obtained from interviews with Administrator, advised that Hospice nurses were treating R1’s wounds and monitoring R1’s general health.
The wound was initially observed by Hospice who completes the full body assessment during showers, a review of the records corroborated this Information obtained from an interview with a Hospice Nurse advised that the facility staff maintain a record of R1’s progress and treatment of their overall health. There was not sufficient evidence to support that R1’s wounds did not recover due to staff neglect. A review of the records revealed that the Hospice Nurses were at the facility two to three times a week to attend to R1's wound.
Regarding the allegation staff do not ensure that resident's dietary needs are met, it was reported that staff put food in front of the residents and leave them slumped over alone to eat. It was stated that R1 required assistance with eating. It was further reported that R1 has lost a significant amount of weight (approximately 30 to 50 lbs.) since being placed at the facility. Information obtained from interviews with facility staff advised that R1 does eat well balanced meals and can feed themselves. It was advised that R1 may need assistance with certain foods, but there are no documented plans regarding eating assistance in R1’s service plan. Interview with Resident was not possible at this time. Interviews with additional residents indicated that there were no concerns with dietary needs being met. A review of the records confirmed R1 is able to eat with her hands but may require assistance if utensils are needed. Additional information obtained from observations revealed that R1 was able to eat without assistance. A review of R1's weight records did not reveal any significant amount of weight loss. Information obtained did not support this allegation.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Venus MixsonTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 04/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5