374604198-4-15-2022-08-AS-DPOL-CDY35M-20220429175655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604198
Report Date: 04/14/2022
Date Signed: 04/15/2022 06:23:58 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
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:	05:00 PM
MET WITH:	Easter Sialoi, Staffing Development Manager, Rachel McIntyre, Intrim Executive Director & Karina Tellez, Business Office Manager		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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- Staff did not discharge resident to a medical facility in a timely manner.
- Staff did not provide resident necessary assistance.
- False claims.
- Facility did not obtain a physician’s Report prior to admission.

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, Easter SialoiSTaffing Development MAnager, Karina Tellez, Business Office Manager.

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

On 10/27/21, it was alleged that staff did not discharge (send out) Resident R1 to a medical facility in a timely manner after a change of condition. Review of documentation determined that R1 had initially been sent out to the hospital on 03/11/21 (1st time) after being observed as unresponsive. Resident was discharged five days later on 03/16/2021 after treatment for an infection. Staff noted that R1 was not at baseline when the resident returned. On 3/22/21, six days later, R1 returned to the hospital for the second time due to weakness to the left side. R1 stayed at the hospital one night and returned to the facility the following day 3/23/21, with new medication orders. Three days later,

Unsubstantiated

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)

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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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on 03/26/21, the resident was sent out to the hospital for the third time due to an observed pressure injury. R1 was not discharged back to the facility but was sent to a skilled nursing facility due to a higher level of care needs. Evidence obtained during the investigation did not support the allegation that staff did not discharge resident to a medical facility in a timely manner.

It was also alleged that staff did not provide necessary assistance for resident R1. Documentation obtained showed the resident was assisted by staff and Physical Therapist on a continual basis. Review of documentation including plan of care (needs and services plan) showed R1 received staff assistance with basic services, including dressing, grooming, prompting for meals and with transfers. Progress notes indicated staff assisted resident with prescribed medication, meals, doctor visits, baseline observations and following physician and Hospice/Home Health orders. Interviews with outside sources did not support the allegation that staff did not provide necessary assistance with basic services. The outside sources recalled observing facility staff assisting resident R1 with meals and transferring. Staff interviews were inconclusive and could not provide relevant information on specific orders or routines involving R1; however, outside sources recalled assisting resident R1 with care when needed. Other outside sources recalled staff ensuring their rounds were completed and in general, residents were routinely checked every two hours. Based on documentation and interviews with outside sources, there is insufficient evidence to support the allegation that staff did not provide resident R1 with necessary assistance.

It was further alleged that the facility was falsely advertising that a former Chief Executive Officer (CEO) was a medical doctor on a Facebook page of Vista Gardens. Documentation from the Medical Board of California dated July 20, 2021 confirmed it had ordered this former CEO to cease and desist from the use of “doctor” or “Dr.” to consumers. However, a review of the former Facebook page dated 11/04/21 did not reveal the name of the former CEO as a “doctor”. A 4/11/22 search of the Facebook website determined the CEO was only mentioned on the site on the following previous dates: 2/17/18, October 24, 2017, and September 22, 2017 in third-party postings, and this individual was referred to as a “Dr.” No other individuals, including the former CEO, are mentioned on the website as being skilled medical professionals after the 6/24/21 date of the Medical Board order. Based on the records reviewed, there is insufficient evidence to support the allegation that the facility was making false claims on a public advertisement.

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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It was also alleged that the facility did not obtain a Physician’s Report prior to R1’s admission. Review of documentation showed there were two completed Physician’s Reports within less than one year of R1’s admission to the facility. Physician’s reports are required annually, based on R1’s cognitive diagnosis. Evidence obtained determined an updated physician’s report was conducted after a change of condition occurred in this resident. Based on documentation obtained during the investigation, there is insufficient evidence to support the allegation that the facility did not obtain a Physician’s Report prior to admission.

The Department has investigated the above-mentioned allegations and based upon the evidence obtained the preponderance of evidence standard was not met, meaning there is insufficient evidence to prove the allegations occurred. The report was discussed with Rachel McIntyre, Interim Executive Director, Easter Sialoi, Staffing Development MMnager, 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)

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