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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 08/04/2022
Date Signed: 08/04/2022 10:37:11 AM

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
10/11/2021 and conducted by Evaluator Esther Miller
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20211011122701
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: 90DATE:
08/04/2022
UNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Amanda Wolfe, Resident Service DirectorTIME COMPLETED:
10:56 AM
ALLEGATION(S):
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Facility is not refunding money owed after residents' death.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced complaint investigation visit to the facility in order to deliver findings on the above allegation. LPA was granted entry to the facility by Amanda Wolfe, Resident Service Director (RSD), after identifying herself and explaining the reason for the visit.

On October 11, 2021, it was alleged that the facility had not provided refunds for four residents after their deaths. The Department’s investigation consisted of review of facility records and interviews of facility staff and outside sources.

[Continued on LIC9099-C, page 1 of 2]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
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 5
Control Number 08-AS-20211011122701
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: 08/04/2022
NARRATIVE
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[Continued from LIC9099, page 2 of 4]

Resident 1 (R1 - see LIC811 Confidential Names List) moved into the facility on April 6, 2021. R1 was enrolled into Community Health Group (CHG) on March 25, 2021. Interviews with staff and outside sources explained that CHG was an insurance program provided to residents to help pay for their board and care. A resident shares the cost (Share of Cost) of the month of rent with CHG by paying for the first few days of the month. This amount is predetermined by Medical and not CHG. Once Share of Cost is exhausted, CHG pays for the rest of the month. Facility records showed that, on March 25, 2021, R1’s responsible party signed a document which stated that after being accepted into CHG, resident is expected to pay $1600 each month. The document also stated that this amount is not prorated when moving in nor refundable after the first of the month. During the application process, or if there was a lapse/termination of insurance, then R1 would be responsible for the private pay rate of $5000. The Admissions Agreement, signed by R1’s responsible party, also showed that rent was $5000.

Facility records and outside interviews confirmed that R1 passed on May 27, 2021. Outside source interview indicated that all of R1’s personal belongings were removed from the facility three to four days after R1’s death. Facility records also indicated that billing stopped on May 28, 2021. Facility records show that two checks dated for June 16, 2022, were given and cashed by the facility on June 21, 2022. $1798 was paid to the facility with check number 687149 with the memo, “[R1] June 2021 Rent”. $1798 was paid to the facility with check number 687150 with the memo, “[R1] May 2021 Rent”. Facility records indicated that an outstanding refund was owed to R1. Staff interview confirmed that a refund was owed and had not been processed. Evidence obtained regarding R1 supports the allegation that the licensee did not provide refund owed after R1’s death.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20211011122701
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: 08/04/2022
NARRATIVE
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Resident 2 (R2) moved into the facility on December 12, 2020. Outside source interviews revealed that R1 was not deceased. R1 was moved from the facility on March 17, 2021 to a different licensed Residential Care Facility. Facility documents showed that R2’s billing stopped on March 18, 2022. Facility records showed that $3825 was due for Respite Care given March 1 – 17, 2022. Facility and outside source records showed that two checks were given and credited to R2’s account. $1287 was credited by the facility on May 13, 2021 with check number 684348 with the memo, “[R2] Rent for May 2021”. $1287 was credited by the facility on June 15, 2022 with check number 686044 with the memo, “[R2] Rent for June 2021”. $1400 was also credited by the facility on May 13, 2022 with check number 683355 with memo “[R2] Economic Impact Payment PIF”. The facility determined that a $959 refund was owed. Facility records and interviews with staff and outside sources confirmed that R2’s responsible party received a refund on August 15, 2021. Evidence obtained regarding R2 did not support the allegation that the licensee did not provide refunds owed after R2’s death because R2 was not deceased.

Resident 3 (R3) moved into the facility on April 1, 2021. Facility records showed that R3 attempted to enroll into CHG but did not become a participant of the insurance program. Facility records and outside source interviews confirmed that R3 passed on July 28, 2021. Facility records and outside source interviews indicated that a credit of $1115 was given by the facility on August 19, 2021. A letter from R3’s payee, dated September 7, 2021, indicated that this money was for August 2021 rent and is now due back by Social Security because R3 had passed. On August 31, 2021, facility and outside source records show that a refund of $1115 was given back to R3’s payee. Facility records and interviews indicated that R3 had an outstanding bill of $3296.12 and payments were being made toward that amount by R3’s responsible party. Evidence obtained regarding R3 does not support the allegation that the licensee did not provide refunds owed after R3’s death.

[Continued on LIC9099, page 3 of 4]
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20211011122701
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: 08/04/2022
NARRATIVE
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Continued from LIC9099-C, page 4 of 4]

Resident 4 (R4 - see LIC811 Confidential Names List) moved into the facility on July 28, 2020. Facility records show that R4 was a participant of CHG. After R3’s death on September 22, 2021, facility records show that billing was stopped on September 24, 2021. Facility records show that a credit of $977 was given by the facility on October 1, 2021. This record also shows that no refund was given or is owed to the resident. Because R4 passed away before October 2021, no fees should have been charged for that month and a refund is owed. Evidence obtained regarding R4 supports the allegation that the licensee did not provide refund owed after R4’s death.

Based on the evidence obtained during the complaint investigation, the allegation that the facility did not provide refunds after resident’s death is found to be SUBSTANTIATED, as there is a preponderance of evidence to show that the violation occurred. Pursuant to the California Code of Regulations, Title 22, Division 6, deficiency is being cited on the attached LIC9099D and a plan of correction was jointly developed with RSD. An exit interview was conducted with RSD; a copy of this report and Licensee's Rights (LIC9058) were provided to RSD.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20211011122701
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2022
Section Cited
HSC
1569.652(c)
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Refund of fees paid: (c) A refund of any fees paid in advance ... covering the time after the resident’s personal property has been removed ... shall be issued ... within 15 days after the personal property is removed. This requirement is not met as evidenced by:
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RSD agreed to provide financial and administrative staff with training on HSC Section 1569.652 and provide signed training logs and training materials. RSD will provide proof of R1's refund. RSD will submit a statement to determine R4's refund status.
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Based on interviews and record reviews, the
licensee did not issue a refund within 15 days
in two of ninety residents
which posed a potential personal rights risk to
residents in care.
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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: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Esther MillerTELEPHONE: 619-672-5843
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5