374604274-6-15-2023-18-AS-JESL-CT6RJQ-20230626130417

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 06/15/2023
Date Signed: 06/15/2023 02:01:56 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
08/15/2022 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220815085156

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: 92	DATE:	06/15/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Johnathan Thomas, Executive Director		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Staff do not distribute medications to resident as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegatios listed noted above. LPA met with Johnathan Thomas, Executive Director and explained the purpose of the visit and the elements of the allegations. The allegations were investigated, the investigation consisted of observation, interviews and a review of pertinent documentation pertaining to the complaint.

Regarding the allegation of staff did not distribute medications to resident as prescribed.
The department received an SIR on August 16, 2022, reporting an incident that occurred on August 10, 2022 regarding, Resident #1 (R1) not receiving their anti seizure medication and having to be sent out via 9-11. At the time of the complaint the usual time given was between 8am-8:30am. Staff reported that there was a delay with the medication being delivered due to the delivery service not delivering the medication on time. A review of R1's medication administration record (MAR) has an entry noting that on 8/9/22 the medication was not delievered and there was follow up with the pharmacy. However, a further review of R1's MAR revealed that on July:7/18/22, 7/19/22, 7/23/22,7/27/22, 7/28/22 and August: 8/19/22, 8/22/22, there

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

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-20220815085156

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: 06/15/2023

NARRATIVE

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are not any signatures recorded confirming that R1's medication was administered as prescribed, based on record review the allegation is SUBSTANTIATED. A substantiated finding means that the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated.

An exit interview was conducted and a copy of this report, appeal rights, 9099D were provided to Johnathan Thomas, Executive Director

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20220815085156

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: 06/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/26/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall... provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange...for medical and dental care appropriate to the conditions and needs of residents. This was not met by:	1 2 3 4 5 6 7	The licensee agrees to conduct a medication administration training highlighting the importance of medications being given as prescribed. Proof of POC is to be submitted to the department by 5pm on the due date indicated. The facility has an inservice scheduled 6/26/23.
	8 9 10 11 12 13 14	The Licensee did not comply with the above regulation with 1 out of 1 residents. As R1 was not given their medication as prescribed on multiple occassions. This is an immedaite health, safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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
08/15/2022 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220815085156

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: 92	DATE:	06/15/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Johnathan Thomas, Executive Director		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

1
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9

Staff did not seek medical attention for resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to deliver findings for the allegation listed noted above. LPA met with Johnathan Thomas, Executive Director and explained the purpose of the visit and the elements of the allegations. The allegations were investigated, the investigation consisted of observation, interviews and a review of pertinent documentation pertaining to the complaint.
Regarding the allegation of staff did not seek medical attention for resident. It was reported that on or around 08/10/2022, R1 received their anti-seizure medication 3.5-4 hours late, this resulted in R1 being sent out for medical observation, as they reported having experienced 3 seizures. R1 was sent out via ambulance to the emergency room for medical evaluation. On 8/16/22, the department received the special incident report stating/confirming that on 8/10/22, that R1 was sent out, based on observation and record review the allegation is UNFOUNDED. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. Therefore, the department had there dismissed the complaint. An exit interview was conducted and a copy of this report was provided to Johnathan Thomas , Executive Director.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 4