374604274-3-22-2023-18-AS-DMUN-CQDRE6-20230329125657

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 03/22/2023
Date Signed: 03/22/2023 12:39:55 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
01/06/2023 and conducted by Evaluator Tricia Danielson

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20230106122510

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: 96	DATE:	03/22/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Johnathan Thomas, Executive Director		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility did not administer medications correctly

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA met with Executive Director Johnathan Thomas and explained the purpose of the visit.
Regarding the allegation "Facility did not administer medications correctly", it was alleged that Resident #1 (R1) was provided a presciption of Plaxovid as ordered. Review of R1's Physician's Orders revealed R1 was prescribed Plaxovid 2 tablets twice a day for 5 days on December 3, 2022. Review of R1's Medication Administrator Records (MARs) revealed R1 was not given Plaxovid on 12/4/22 because it had not yet been delivered from the pharmacy. There was no documentation done to show it as given or not given on 12/5/2022 AM but the MARs indicated Plaxovid was given 12/5/22 at 8:00 PM. No documentation was completed to show it was given or not given on 12/6/22 and it was documented on 12/7/22 and 12/8/22 that it was not given because it had not been delivered from the pharmacy. Further review of R1's MARs revealed Plaxovid was given as prescribed 12/9/22 through 12/12/22. On 12/13/22 as well as 12/14/22, there was no documentation to show it was given or not given for the AM doses however, it was documented as given for the PM doses. Plaxovid was given for both AM and PM doses on 12/15/22. (CONTINUED ON LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

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 18-AS-20230106122510

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: 03/22/2023

NARRATIVE

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(CONTINUED FROM LIC9099)
Both AM and PM doses were held on 12/16/22 and 12/17/22 and documented "withheld per DR/NP orders". There was no documentation done to show it as given or not given on 12/18/2022 AM and was documented as "withheld per DR/NP orders" for the 12/18/22 PM dose. However, the MAR then indicated Plaxovid was given to R1 for the 12/19/22 AM dose. On 12/20/22 and 12/21/22, all doses were "withheld per DR/NP orders". In total, R1's MARs indicated R1 was provided 14 doses of a 10 dose prescription. Review of R1's MARs revealed no documentation that R1 refused any doses of Plaxovid and interview with facility Resident Services Director (RSD) revealed R1 was not known to refuse medication. Per RSD, and inservice has already been conducted with all med tech staff regarding the importance of following up with every unmarked MAR dose or those marked with an exception, notifying the doctor and responsible party if any medication is refused, and ordering refills promptly.
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), are being cited on the attached LIC 9099 D. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names list and Appeal Rights.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20230106122510

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: 03/22/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/29/2023 Section Cited CCR 87465(j)	1 2 3 4 5 6 7	Incidental Medical and Dental Care- (j) In all facilities licensed for sixteen (16) persons or more, one or more employees shall be designated as having primary responsibility for assuring that each resident receives...and for assisting residents as needed with self-administration of medications. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The facility has already conducted re-training of med tech staff regarding the importance of following up with every unmarked MAR dose or those marked with an exception, notifying the doctor and responsible party if any medication is refused, and ordering refills promptly. Proof of training has been provided to LPA. This deficiency was cleared at the
	8 9 10 11 12 13 14	The Licensee did not ensure assistance was provided with self-administration of medications. Based on records reviewed and interviews conducted, R1 was not provided assistance with their prescription of Plaxovid as ordered. This poses a potential health, safety, and personal rights risk to residents in care.	8 9 10 11 12 13 14	time of the visit.
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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: Deborah Mullen	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia Danielson	TELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2023

LIC9099 (FAS) - (06/04)

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