374604198-9-25-2025-18-AS-RORN-DM2NX8-20251001105041

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604198
Report Date: 09/18/2025
Date Signed: 09/25/2025 09:41:49 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
08/23/2022 and conducted by Evaluator Sparkle Day

COMPLAINT CONTROL NUMBER: 18-AS-20220823140958

FACILITY NAME:	VISTA GARDENS		FACILITY NUMBER:	374604198
ADMINISTRATOR:	JAMES MCALEER		FACILITY TYPE:	740
ADDRESS:	1863 DEVON PLACE		TELEPHONE:	(760) 295-3900
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	0	CENSUS:	DATE:	09/18/2025
		UNANNOUNCED	TIME BEGAN:	08:19 AM
MET WITH:			TIME COMPLETED:	08:20 AM

ALLEGATION(S):

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Staff abandoned resident.

INVESTIGATION FINDINGS:

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On 8/26/22 at 09:04am, Licensing Program Analyst (LPA) Venus Mixon conducted the intial investigation visit to ascertain information regarding the above-mentioned allegation and for the purpose of rendering the finding. LPA met with Karina Tellez, Office Manager who assisted with the visit.

The investigation consisted of the following:
Allegation: Staff abandoned resident
It is Alleged the facility staff brought R#1 to Palomar Medical Center for behavior and aggression issues and would not pick up R#1when Medical Center called for pick up.
On 8/26/22 LPA Mixson interviewed Office Manager,Karina Tellez (S2) and two staff regarding the allegation. LPA also reviewed and obtained pertinent documents regarding this investigation. On12/22/22 LPM Deborah Mullen interviewed Administrator Rachel McIntyre (S1) via phone regarding the allegation Administrator denied the allegation and stated R#1 was not abandoned. R#1 was brought to the Medical Center for evaluation due to R#1 had been experiencing a change in behavior where R#1 was walking into other resident's rooms and when staff tried to redirect R#1 would become combative. R#1was also

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

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 18-AS-20220823140958

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VISTA GARDENS	FACILITY NUMBER: 374604198
	VISIT DATE: 09/18/2025

NARRATIVE

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began withdrawing into his room and wouldn't come out. R#1 wouldn't shower and later found out R#1 was hoarding food and pills that R#1 was not swallowing, in their room. R#1 began refusing to take medications and was also saying they wanted to kill the other residents in the facility and that they wanted to kill themselves. After Administrator spoke with R#1's doctor it was discussed R#1 would go on a 72 hour hold at the Medical Center. The Medical Center called after 4-6 hours to pick up R#1 and this is not what was discussed with the doctor. So Administrator stated she was waiting to talk to doctor before picking up R#1. 4 out of 4 staff interviews denied the allegation. On 8/26/22 LPA Mixson toured the facility inside and out and found there were no Title 22 Division 6 Regulation violations observed and no citations were issued at time of visit.

On 9/18/25 LPA Sparkle Day conducted the follow up investigation. During the follow up investigation, it was determined R1 never returned to the facility after he was taken to the Clinic. R1 was discharged from hospital and moved into another facility on 8/29/22 and left that facility on 9/14/22. The resident's record was not available for review as it has been 3 years since the discharge date. R1's current whereabouts are unknown. Attempts were made to contact the reporting party to obtain additional information, however that individual could not be reached and can no longer be contacted with the phone number provided.

This Facility Closed on 7/29/2024

Based upon this investigation, LPA finds that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED

A copy of this report will be mailed to last mailing Address: 1863 Devon Place Vista , CA 92084 by LPA Sparkle Day on 9/25/25

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Sparkle Day
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

LIC9099 (FAS) - (06/04)

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