<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604198
Report Date: 04/14/2022
Date Signed: 04/15/2022 06:25:20 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
06/07/2021 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20210607164333
FACILITY NAME:VISTA GARDENSFACILITY NUMBER:
374604198
ADMINISTRATOR:DELGADO, EVELYNFACILITY TYPE:
740
ADDRESS:1863 DEVON PLACETELEPHONE:
(760) 295-3900
CITY:VISTASTATE: CAZIP CODE:
92084
CAPACITY:99CENSUS: 80DATE:
04/14/2022
UNANNOUNCEDTIME BEGAN:
06:00 PM
MET WITH:Karina Tellez, Business Office Manager and Rachel McIntyre, Intrim Executive DirectorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Resident sustained unstageable pressure injury due to neglect.
- Staff did not notify authorized representative about change of resident health condition.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Carmen Lopez, conducted an unannounced visit to the facility to deliver findings for a complaint investigation regarding the above-mentioned allegations. LPA Lopez identified herself and was granted entry by Edith Osio, Concierge. LPA stated the purpose of the visit with Rachel McIntyre, Interim Executive Director and Karina Tellez, Business Office Manager.

The Department’s investigation consisted of the review of records, interviews with staff and outside sources which were pertinent to this investigation.

On 6/07/2021, it was alleged that resident R1 (see LIC811, Confidential Names) sustained an unstageable pressure injury due to staff neglect. Review of records confirmed that R1 was sent to the hospital three times within a one-month period. On 3/11/21, R1 was sent to the hospital for the first time after being observed as unresponsive and the authorized representative was notified. On 3/16/21, R1 was
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: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
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-20210607164333
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: 04/14/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
discharged from the hospital and returned to the facility. On 3/17/21, the facility noticed that R1 was not at baseline, unable to ambulate on own, and was using the wheelchair to ambulate. On 3/22/21, R1 was found to be favoring one side of the body. A visiting doctor was at the facility and was notified regarding resident’s condition. Physician found a coccyx pressure injury wound and ordered home health (HH) for R1. Facility sent R1 to the hospital the same day, 3/22/21 for a condition unrelated to the pressure injury. An interview with outside/sources confirmed that R1 had left side weakness and was taken to the hospital due to stroke-like symptoms. R1 stayed at the hospital that night. R1 was discharged and returned to the facility on 3/23/21.

Upon the resident’s return, Home Health Nurse (HHN) was ordered specifically for the pressure injury on 3/24/21 by facility staff. Resident was already on HH for unrelated services. Interviews with staff were inconsistent with the records reviewed and maintained that R1 obtained the pressure injury while at the hospital during their stay on 3/22/21 – 3/23/21. Staff indicated that the pressure injury was observed on 3/24/21. Facility staff observed the pressure injury and notified physician and outside agency. R1’s responsible party was notified and informed of the pressure injury on 3/25/21. According to interview statements the in house physician stated that on 3/24/21, R1 had a stage II pressure injury and was sent to the hospital. HH was immediately ordered for treatment. On 3/25/21 HHN determined the pressure injury was now a Stage III. On 3/26/21, R1 was sent to the hospital for treatment of the pressure injury. R1 was discharged to a skilled nursing facility on 3/29/21 where the pressure injury worsened to a Stage IV (unstageable). Dates were inconsistent; however, records reviewed during the investigation showed that the hospital had no notes or documentation regarding concerns for neglect. Based on the interviews and records reviewed, there is insufficient evidence to prove that sustained unstageable pressure injury was due to neglect.

It was also alleged that staff did not notify the authorized representative about the change of resident’s health condition for the pressure injury sustained. Facility records indicated that the facility had ongoing communication with the authorized representatives regarding the condition of the resident. Per notes in facility records the authorized representative for R1 was notified on 3/22/21 when R1 was sent to the hospital and again on 3/25/21 regarding
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 08-AS-20210607164333
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: 04/14/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
the pressure injury. Documentation and interviews with staff and outside sources confirmed that if one authorized representative was unavailable, the facility would make contact with the back-up authorized representative to report the updates of R1. Additionally, interviews with outside sources confirmed they maintained ongoing communication, regarding R1’s condition with the authorized representative(s).

Based on the documentation gathered and interviews with outside sources, there is insufficient evidence to support the allegation that staff did not communicate with authorized representative about R1’s change of condition.

The Department has investigated the above-mentioned allegations and based upon the evidence obtained during interviews and records reviewed, it is determined that there is insufficient evidence to prove that the allegations occurred. Therefore, the allegations are deemed to be unsubstantiated.

The report was discussed with Rachel McIntyre, Interim Executive Director and Karina Tellez, Business Office Manager and a copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to the Rachel McIntyre, Interim Executive Director via email. An electronic email receipt 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: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3