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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604198
Report Date: 11/02/2023
Date Signed: 01/23/2024 01:52:49 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
04/24/2020 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20200424150232
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: 88DATE:
11/02/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH: Rachel McIntyre, Health and Wellness Director, and Karina Tellez, Business Office ManagerTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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- Staff neglect lead to resident sustaining injuries
- Licensee failed to notify authorized representative of resident's change of condition.
- Licensee failed to provide a copy of Admission Agreement to resident's authorized representative.


“This is an amended version of the original report created on 11/02/2023."
INVESTIGATION FINDINGS:
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On November 2, 2023 Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings on the above allegations and conclude the investigation. LPA met with Rachel McIntyre, Health and Wellness Director and Karina Tellez, Business Office Manager, and reviewed the findings.

On April 24, 2020, it was alleged that staff neglect resulted in a resident #1 (R1) sustaining injuries at the facility. The Department’s investigation consisted of interviews with staff and outside sources, and record reviews of pertinent documents, including medical records. Investigation revealed R1 resided at the facility from December 2, 2019, until March 4, 2020. R1 had a primary diagnosis of dementia and was ambulatory with the use of a walker. R1 had a history of falls prior to admission, and was assigned to a memory care unit for residents that needed additional care and closer monitoring from staff. Records showed that R1 was moved to a different unit, intended for higher functioning residents, at the request of the resident’s responsible party. Facility staff advised against this move, due to R1’s history of falls and level of cognitive impairment. (Continued on next page)
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: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
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 08-AS-20200424150232
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: 11/02/2023
NARRATIVE
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On December 12, 2020, R1 fell, resulting in facial injuries and a lacerated thumb. According to medical records, R1 was sent to the hospital for treatment, then discharged back to the facility the same day, with sutures and a bandaged thumb. R1 later developed an infection on their thumb, caused by repeatedly picking apart the sutures, and was sent back to the hospital on January 6, 2020. While at the hospital, an x-ray revealed a dislocation of the same thumb, that had not been detected during the first visit. R1 had orthopedic surgery and their hand was placed in a cast, with prescribed antibiotics for the infection. Facility records showed staff ensured medical attention was obtained, provided follow up care and monitored R1’s progress, including a subsequent change in health condition as a complication of the infection. There was insufficient evidence to support the allegation that staff neglected R1, resulting in injuries.

It was further alleged that staff failed to notify R1’s authorized representative regarding a change in condition. Facility records revealed internal communication notes and progress reports that charted the fall incident, and documented notification was made to R1’s authorized representative and also to the resident’s primary care physician. Interviews confirmed staff communicated with R1’s authorized representative on a regular basis, and reported any change of condition. There was insufficient evidence to support the allegation that facility staff did not notify R1’s authorized representative about a change of condition.

The Department has investigated these allegations and has determined them to be unsubstantiated, meaning although the allegations could have happened or be valid, the preponderance of evidence standard has not been met. An exit interview was conducted, and a copy of this report along with licensee rights was provided to facility representative Rachel McIntyre, Health and Wellness Director whose signature below confirms receipt of these rights.

“This is an amended version of the original report created on 11/02/2023."
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/24/2020 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20200424150232

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: 88DATE:
11/02/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rachel McIntyre, Heal and Wellness Director, and Karina Tellez, Business Office ManagerTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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- Unlawful eviction
- Licensee failed to follow admission agreement related to refund



“This is an amended version of the original report created on 11/02/2023."
INVESTIGATION FINDINGS:
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On November 2, 2023 Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings on the above allegations and concluded the investigation. LPA met with Rachel McIntyre, Health and Wellness Director, and Karina Tellez, Business Office Manager, and reviewed the findings.

On April 24, 2020, it was alleged that the facility unlawfully evicted a resident #1 (R1). It was specifically alleged that staff refused to allow R1 to return to the facility, after hospitalization and treatment for an infectious condition. The Department’s investigation consisted of interviews with staff and outside sources, and record reviews of pertinent documents, including medical records. Investigation revealed R1had a primary diagnosis of dementia and was ambulatory with the use of a walker. On December 12, 2020, R1 fell, resulting in facial injuries and a lacerated thumb. According to medical records, R1 was sent to the hospital for treatment, then discharged back to the facility the same day, with sutures and a bandaged thumb. R1 later developed an infection on the thumb and was sent back to the hospital on January 6, 2020.
(Continued on next page)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20200424150232
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: 11/02/2023
NARRATIVE
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While at the hospital, an x-ray revealed a dislocation of the same thumb. R1 had orthopedic surgery, and their hand was placed in a cast, with prescribed antibiotics for the infection.

On or about February 26, 2020, because of their infected thumb, R1 developed a highly infectious bacterial condition identified as Clostridium Dificile (“C-Diff”). The treating physician subsequently evaluated R1 as asymptomatic and did not recommend re-testing since there was no active C-Diff. Medical records noted R1’s symptoms had improved with oral medications, and R1 was evaluated as stable and ready for discharge from a skilled nursing facility on March 3, 2020. However, staff refused to allow R1 to return, in violation of their own Infection Control policy regarding C-Diff. Review of facility policy records noted that any resident with C-Diff should reside in a private room and not share a bathroom with other residents. The policy stated that preventive measures would be taken to prevent C-Diff infections among residents, including using standard precautions while caring for a resident with C-Diff at the facility. Records showed that during R1’s stay in the skilled nursing facility, R1 was placed with roommates and allowed to dine in common areas, since they were evaluated as no longer contagious. On March 13, R1 was admitted to another licensed care facility.

It was also alleged that the facility did not provide a copy of R1's signed admission agreement to their authorized representative and did not provide a refund. There were conflicting interview statements by outside sources; however, review of records obtained during the investigation showed a copy of the admission agreement was given at the time of R1's admission, and a partial refund of prepaid fees was issued to their responsible party, as required. Although a partial refund was issued, the amount the facility refunded was incorrectly calculated. Based on records, the resident was initially turned away by the facility when R1 was discharged by the hospital on March 3, 2020. As such, the refund should have been pro-rated as of said date. The facility refunded R1’s responsible party a partial refund of about one week's worth for the month of March 2020. The facility did not refund the full amount that was owed to the family. Based on the information obtained there is sufficient evidence to support the allegation.

There was sufficient evidence to support the allegations that the facility did not allow R1 to return without providing a required eviction notice, resulting in an unlawful eviction and the facility did not allot the family their full refund based on the admission agreement. The Department has investigated this allegations and has determined it to be Substantiated, meaning the preponderance of evidence standard has been met. The deficiencies were cited on the attached LIC9099-D form. An exit interview was conducted, a plan of correction was jointly developed, and a copy of this report along with licensee rights was provided to facility representative Rachel McIntyre, Health and Wellness Director whose signature below confirms receipt of these rights.

“This is an amended version of the original report created on 11/02/2023."
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20200424150232
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2023
Section Cited
CCR
87224(a)(4)
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87224 Eviction Procedures (a)(4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident. This requirement is not met as evidenced by:
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The facility will conduct directorate training for all involved staff regarding eviction procedures, by POC due date.

POC was cleared during the visit on 01/23/2024.
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Based on records review, the licensee did not follow eviction procedures and evicted R1 for a reason not listed in section 87224 (a)(1) through (5), which poses a health and risk to 1 [R1] of 72 person in care.
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“This is an amended version of the original report created on 11/02/2023.”
Type B
02/09/2024
Section Cited
CCR
87468.2(a)(8)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidenced by:
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The facility will be refunding the resident's family the remaining balance of $3,244.77 and send LPA a photo of the mailed refund (certified mail and a copy of the check). Facility will also provide in-service training to Directorate staff which includes HR, Marketing, Business Office and Executive Director by POC due date, 02/09/24.
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Based on records review, the licensee did not follow this section by not financially exploiting R1, which poses a Personal Rights risk to 1 [R1] of 72 person in care.
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“This is an amended version of the original report created on 11/02/2023.”
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5