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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 05/11/2022
Date Signed: 05/11/2022 12:19:05 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2022 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220506143548
FACILITY NAME:VISTA DEL LAGO MEMORY CAREFACILITY NUMBER:
374604274
ADMINISTRATOR:GONZALEZ, JEFFFACILITY TYPE:
740
ADDRESS:1817 AVENIDA DEL DIABLOTELEPHONE:
(760) 741-2888
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:96CENSUS: 84DATE:
05/11/2022
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Hilda Paz Sanchez, Community Relations DirectorTIME COMPLETED:
11:29 AM
ALLEGATION(S):
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Staff did not have access to resident's emergency paperwork.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation for the allegation listed above. LPA met with Hilda Paz Sanchez, Community Relations Director and explained the purpose of the visit. The investigation consisted of observation, interviews and record review of resident files.

Regarding the allegation of staff did not have access to resident's emergency paperwork, it was revealed through interviews that the resident files are locked inside of the Business Office Manager's office. The individuals identified to having access to the office are the Executive Director, Lead Medical Technician (Med Tech), and Business Office Manager, should the file be needed after hours the Lead Med Tech or staff from nursing team would be the one access the office. The emergency paperwork that is sent out is Med list, copy of POLST, ID, face sheet and hospice documentation if applicable.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
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 18-AS-20220506143548
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VISTA DEL LAGO MEMORY CARE
FACILITY NUMBER: 374604274
VISIT DATE: 05/11/2022
NARRATIVE
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Additionally during interviews conducted it was admitted that staff did not have access to all resident information such as financial and the admission agreement, as they are housed in a separate office in a different folder and only two staff have access, which resulted in staff not having access to resident's emergency paperwork.

The staff that had access (Business Office Director and Resident Services Director were not on shift at the time of when the request for documentation was needed. Therefore the allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted and a copy of this report, 9099D and appeal rights were provided to Hilda Paz Sanchez, Community Relations Director

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20220506143548
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VISTA DEL LAGO MEMORY CARE
FACILITY NUMBER: 374604274
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/01/2022
Section Cited
CCR
87506(a)
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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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The licensee agrees to roll out the electronic file PCC program that will give staff access to all resident information and print wha is needed. Proof is to be submitted by 5pm on the due date indicated.
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This requirement is not met as evidenced by: the facility staff did not have access to the resident's emergency paperwork when needed when a resident was sent out.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3