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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604198
Report Date: 01/23/2024
Date Signed: 01/23/2024 05:50:45 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/04/2020 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20200604100543
FACILITY NAME:VISTA GARDENSFACILITY NUMBER:
374604198
ADMINISTRATOR:HUNDLEY, SHANNONFACILITY TYPE:
740
ADDRESS:1863 DEVON PLACETELEPHONE:
(760) 295-3900
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:99CENSUS: DATE:
01/23/2024
UNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Rachel McIntyre, Health and Wellness DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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- Unskilled medical professionals administering injections
- Lack of staff to meet residents needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by Cindy Jimenez, Receptionist. LPA stated the purpose of the visit and reviewed the findings of the complaint with Health and Wellness Director Rachel McIntyre.

The Department’s investigation consisted of interviews with staff and outside sources, records review of relevant documents pertinent to this investigation, and LPA observations. On June 4, 2020, it was alleged that the facility had unskilled medical professionals administering injections and there was a lack of staff to meet the residents’ needs.

On 6/04/2020 it was alleged that unskilled medical professionals, specifically S1, were administering injections, specifically insulin and liquid morphine to Resident #1 (R1) (see LIC811 confidential names list). Further information revealed that the staff did not administer R1 the insulin as it was removed from S1’s possession by a skilled medical professional.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
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 3
Control Number 08-AS-20200604100543
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: VISTA GARDENS
FACILITY NUMBER: 374604198
VISIT DATE: 01/23/2024
NARRATIVE
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Interview with former staff revealed that there were no medication technicians that provided liquid morphine via syringe to residents. Medication Technicians (med tech) were trained only to provide capsules and tablets and were aware that either the Licensed Vocational Nurses (LVN’s) or the resident’s hospice nurses were the assigned medical professionals who were able to administer injections to the residents. Staff interviewed revealed that they do assist residents with their insulin medications, but they use the flex-pens which the residents administer themselves. The staff said that they assist residents with hand over hand if the resident is in need, but the residents are responsible for administering their insulin flex-pen themselves; staff merely place their hands over the residents’ hand to assist them, but residents will push the flex-pen themselves. According to staff, they receive training via their internal system, then conduct shadowing for about two weeks and finally conduct an examination to complete their training. According to staff, they do have a third- party vendor who provides staff training on medications at least every six months or on an as needed basis. Current MARs show that the med techs do sign the MAR to ensure that they annotate that the resident had received their insulin. Based on the interviews and records reviewed, there is insufficient evidence to prove that unskilled professionals administered injections.

It was specifically alleged that there was a lack of staff to meet the residents’ needs. A former staff said that the facility did work with third party vendors to fill in for the staff shortage and attempt to contract the same person’s as they were familiar with the residents. Interview with a former staff said that the facility staff never had residents lay in soiled briefs for hours at a time, but staffing was a challenge. Additional staff corroborated with saying that there was a high turnover of staff, but staff would always ensure that the residents were assisted in their needs and checking them about every two hours. Staff recalled that they were good about changing and turning the residents. Staff mentioned that if assistance was needed, they would be able to communicate via radio that assistance was needed. According to staff and former staff who were interviewed, it was said that they believed they did not have sufficient staff but not to the point where they were not meeting the residents’ needs. A review of former complaint, control number 08-AS-20191204083608, it should be noted that a similar allegation of inadequately staffed to meet the needs of residents was generated and delivered 10/01/2020 and included that although they may have been short on caregivers’ other staff would assist which included med techs and management staff to ensure that the need’s of residents were met. Based on the information obtained during the investigation, there was insufficient evidence to prove that there was a lack of staff to meet the residents’ needs.

Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff and outside sources interviews and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be unsubstantiated.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20200604100543
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: VISTA GARDENS
FACILITY NUMBER: 374604198
VISIT DATE: 01/23/2024
NARRATIVE
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The report was discussed, and an exit interview was conducted with Health and Wellness Director Rachel McIntyre. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to Health and Wellness Director McIntyre, at the conclusion of the visit. The signature below confirms the documents were received.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 01/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3