374604198-4-15-2022-08-AS-DPOL-CDY35L-20220429175655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604198
Report Date: 04/14/2022
Date Signed: 04/15/2022 06:24:39 PM

Substantiated

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
10/27/2021 and conducted by Evaluator Carmen Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20211027144648

FACILITY NAME:	VISTA GARDENS		FACILITY NUMBER:	374604198
ADMINISTRATOR:	DELGADO, EVELYN		FACILITY TYPE:	740
ADDRESS:	1863 DEVON PLACE		TELEPHONE:	(760) 295-3900
CITY:	VISTA	STATE: CA	ZIP CODE:	92084
CAPACITY:	99	CENSUS: 80	DATE:	04/14/2022
		UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Rachel McIntyre, Intrim Executive Director, and Karina Tellez, Business Office Manager		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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- Facility did not meet resident assessed needs.
- Facility did not complete a pre-admission appraisal for resident.

INVESTIGATION FINDINGS:

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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, and interviews with staff and outside sources which were pertinent to this investigation.

On 10/27/2021, it was alleged that the facility was not meeting the assessed needs of the residents, R1 and R2 (see LIC811, Confidential Names). A review of the documentation for R1 revealed that R1’s assessed needs included verbal prompts for showering and meals, assistance with dressing and grooming, escorting to activities, and assistance with medication. Documentation does reveal assessed needs for R1, R1’s needs did start to change. On 3/11/21 resident was sent to the hospital for being unresponsive.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (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 4

Control Number 08-AS-20211027144648

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

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While resident was out at the hospital, there was an annotation on 3/14/21 that resident needed PeriGuard ointment applied topically to the bilateral buttock area every day for prophylaxis (intended to prevent disease). A website search of PeriGuard ointment reveals that the ointment is a protectant that helps relieve and prevent rashes and irritation due to wetness from incontinence. According to records, the facility had PeriGuard as an active order for R1 since 1/29/21. There is no documentation to indicate whether ointment was applied to R1. R1 was discharged and returned to the facility on 3/16/2021. On 3/17/21, it was noted that R1 was not at baseline and was unable ambulate on own. On 3/22/21, a new order from a medical professional for R1 was received. The physician ordered home health nurse (HHN) services for a coccyx pressure injury wound for R1. Although the order was received on 3/22/21, R1 was sent to the hospital for a condition unrelated to the pressure injury. Documentation for R2 indicated R2 needed assistance with incontinence care, bathing, grooming, and medications. Interviews with outside sources did not support the allegation that the facility did not meet the residents’ assessed needs. Staff and outside sources were inconsistent with their interviews regarding R1 but confirmed that R2 was receiving staff assistance when requested. Interviews with staff revealed that any changes in resident R2’s condition were properly documented, and staff ensured assessments were completed. Records for R2 were current and complete; however, records for R1 were not current and a reappraisal was not conducted after R1’s change of condition. Based on evidence obtained during the investigation, there is sufficient evidence to support that staff did not meet the assessed needs for R1.

It was also alleged that the facility did not complete the pre-admission appraisal for R1. In review of resident records, it was determined that the facility did not have a completed pre-admission appraisal for the resident. The undated form had R1’s name, physical disabilities, and ambulatory status and was signed by staff. The two-page document was incomplete and much of the content had been left blank. During interviews with outside sources, they assumed that questions that were being asked by facility staff regarding R1 were part of the pre-admission appraisal. In interview statements, staff acknowledged that the pre-admission appraisal was not completed as required by regulations. Evidence obtained during the investigation supported the allegation that staff did not complete a pre-admission appraisal for R1.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (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)

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Control Number 08-AS-20211027144648

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

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The Department has investigated the above-mentioned allegations and based upon the evidence obtained the preponderance of evidence standard was met, meaning there is sufficient evidence to prove the allegations occurred. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099D.

The report was discussed and plan of correction was jointly developed 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 Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (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 4

Control Number 08-AS-20211027144648

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: 04/14/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/29/2022 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of Resident states “…When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.” This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Intrim ED will provide in-service training on Relias an online training, review Title 22 Regulations, and review handbook for nursing staff. Proof of in-service training to be provided to CCL by POC date, Friday, April 29, 2022.
	8 9 10 11 12 13 14	Based on records reviewed the Facility did not ensure that R1’s was reappraised for a change in condition after hospitalization. This posed a potential safety risk to 1 out of 57 residents in care.	8 9 10 11 12 13 14
Type B 04/29/2022 Section Cited CCR 87457(c)(1)(A)	1 2 3 4 5 6 7	87457(c)(1)(A), Pre-Admission Appraisal – “Prior to admission and determination of the prospective resident’s suitability for admission shall be completed and shall include an appraisal of his/her individual service … The licensee shall be permitted to use the form LIC 603 (Rev. 6/87), Preplacement Appraisal Information, to document the appraisal.” This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Intrim ED will provide in-service training on the completion of forms. Proof of in-service training to be provided to CCL by POC date, Friday, April 29, 2022.
	8 9 10 11 12 13 14	Based on record review the Facility did not ensure that R1’s Preplacement Appraisal Information was documented or completed prior to admission. This posed a potential safety risk to 1 out of 57 residents in care.	8 9 10 11 12 13 14

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 Powell	TELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Carmen Lopez	TELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC9099 (FAS) - (06/04)

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