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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 12/11/2024
Date Signed: 12/11/2024 01:26:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
11/25/2024 and conducted by Evaluator Janette Romero
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20241125114737
FACILITY NAME:VISTA DEL LAGO MEMORY CAREFACILITY NUMBER:
374604274
ADMINISTRATOR:MARIE HILLFACILITY TYPE:
740
ADDRESS:1817 AVENIDA DEL DIABLOTELEPHONE:
(760) 741-2888
CITY:ESCONDIDOSTATE: CAZIP CODE:
92029
CAPACITY:96CENSUS: 91DATE:
12/11/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Marie HillTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Neglect
INVESTIGATION FINDINGS:
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On 12/11/2024, Licensing Program Analyst (LPA), Janette Romero arrived unannounced to deliver investigative findings regarding the allegation listed above. LPA met with Administrator, Marie Hill who was informed of the purpose of the visit.

It was alleged Resident 1 (R1) sustained a cut on Sunday, 11/17/2024 and the facility did not seek appropriate medical attention. LPA reviewed R1’s Physician’s Report (LIC 602A) dated 1/5/2024 noting R1 exhibits confusion, wandering behavior, and is unable to communicate their needs or follow instructions. Facility staff on duty at the time of the discovery of the wound contacted Resident Services Director (RSD), Priscilla Bermudes for further instruction based on the severity of the wound. RSD was interviewed and reported on 11/17/2024, they received a phone call from facility staff reporting R1 was observed with an open area to their lower left leg. RSD added they also received a photograph of the wound and directed facility staff to not activate emergency services. RSD explained facility staff reported R1 did not express pain and RSD viewed the photograph, and the wound was not actively bleeding. Therefore in RSD's opinion, facility staff could manage the wound and R1 did not require emergency services. RSD reported the source of the injury is unknown.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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-20241125114737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: VISTA DEL LAGO MEMORY CARE
FACILITY NUMBER: 374604274
VISIT DATE: 12/11/2024
NARRATIVE
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RSD reported they instructed facility staff to clean the wound, put antibiotic ointment and bandage it. RSD reported the facility contacted R1's physician's office at San Diego PACE and requested home health services for wound care while the facility's licensed vocational nurses treated the wound and changed the dressing on a daily basis. RSD reported Mismo Dermatology assessed R1 on 11/19/2024. LPA contacted Mismo Dermatology who reported a Physician's Assistant (PA) was at the facility when staff requested they assess R1's wound. Mismo Dermatology reported the PA assessed the wound and determined it was too late for R1 to receive stitches. RSD reported R1's Responsible Person (RP) was notified of the wound and declined emergency services for R1. LPA conducted an interview with R1's RP who reported they were notified of the wound but RSD minimized the severity of the wound and reiterated the wound could be managed by facility staff. R1's RP reported facility staff never offered them the option to send R1 to the hospital. R1's RP reported when R1's family observed the wound in person, they were concerned with the severity of the wound and contacted San Diego PACE who requested to see R1 in their office. On 11/20/2024, R1's RP transported R1 to San Diego PACE to address the wound. LPA reviewed R1’s Medical Visit Summary from San Diego PACE noting on 11/20/2024 R1 visited their physician, at San Diego PACE's request, and was observed with an uncovered open wound measuring 6 centimeters by 2 centimeters with no discharge, edges with eschar tissue, no erythema around the wound, and subcutaneous tissue exposed. The MVS noted the wound required stitches and R1 was referred to the emergency department following their doctor’s visit. Based on interviews conducted, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099 D. An exit interview was conducted, and a copy of this report was reviewed and provided to Administrator Hill along with a Confidential Names list (LIC 811) and Appeal Rights.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20241125114737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/11/2024
Section Cited
CCR
87465(a)(1)
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(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by:
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Licensee reported the facility will conduct an all staff in-service training regarding incidental medical care. POC to be submitted to LPA by close of business on 12/20/2024.
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Based on interviews conducted and records reviewed, R1 sustained a wound that required stitches and RSD instructed facility staff to not activate emergency services and treat the wound instead. This poses a potential health, safety, and 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.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Janette Romero
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
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