374604274-5-27-2022-08-AS-JRAE-CFVRUY-20220630132042

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 05/27/2022
Date Signed: 05/27/2022 11:38:56 AM

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
01/25/2022 and conducted by Evaluator Kayla Hilario

COMPLAINT CONTROL NUMBER: 08-AS-20220125101732

FACILITY NAME:	VISTA DEL LAGO MEMORY CARE		FACILITY NUMBER:	374604274
ADMINISTRATOR:	GONZALEZ, JEFF		FACILITY TYPE:	740
ADDRESS:	1817 AVENIDA DEL DIABLO		TELEPHONE:	(760) 741-2888
CITY:	ESCONDIDO	STATE: CA	ZIP CODE:	92029
CAPACITY:	96	CENSUS: 87	DATE:	05/27/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Administrator Jeff Gonzalez		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Licensee did not give resident their records.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Kayla Hilario, conducted an unannounced visit to deliver findings regarding the above-mentioned allegation. LPA was allowed entry by receptionist and met with Administrator Jeff Gonzalez. LPA identified herself and discussed the purpose of the visit.

The Department’s investigation included a tour of the facility, observations, records reviews, and interviews with staff and outside sources. Prior to the investigation, LPA interviewed the reporting party and reviewed the facility file.

It was alleged that Licensee did not give resident their medical records. A review of resident records indicated that the request for medical records was not made by the appropriate party which would be the resident, or their responsible party, or Power of Attorney. Further, the request was not made in writing as per facility procedure. Interviews with staff determined that facility protocol was followed, and that at the time of request, the requester was advised of proper procedure for requesting medical records.
...continued on 9099c.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla Hilario	TELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

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-20220125101732

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 DEL LAGO MEMORY CARE	FACILITY NUMBER: 374604274
	VISIT DATE: 05/27/2022

NARRATIVE

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Requester was also notified of proper procedure in a follow-up phone voice message in which the call was not returned. In addition, the resident’s responsible party stated that they have never had any issues requesting and obtaining resident records on behalf of the resident in question who is not able to advocate for themself.

Based on review of records, interviews, and outside sources, the investigation did not produce substantial evidence to meet the preponderance of evidence standard; therefore, the allegation is found UNSUBSTANTIATED.

An exit interview was conducted with Administrator Jeff Gonzalez. A copy of this report and Licensee's (LIC 9058 01/16) were provided to the Administrator via hardcopy at the conclusion of the visit.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla Hilario	TELEPHONE: (619) 481-0844
LICENSING EVALUATOR SIGNATURE:	DATE: 05/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022

LIC9099 (FAS) - (06/04)

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