374604274-7-8-2022-18-AS-JESL-CU9MQ8-20230731094819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 07/08/2022
Date Signed: 07/08/2022 03:32:58 PM

Unsubstantiated

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
06/30/2022 and conducted by Evaluator Jesse Gardner

COMPLAINT CONTROL NUMBER: 18-AS-20220630090754

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: 84	DATE:	07/08/2022
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Amanda Wolfe, Resident Services Director		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident medical equipment was missing functional parts.
Staff speak inappropriately to resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility unannounced in order to initiate an investigation of a complaint with the above allegation(s). LPA identified himself and discussed the purpose of the visit with Resident Services Director Amanda Wolfe (S1). S1 accompanied LPA on a tour the facility and found that 84 residents are in the facility with 20 staff.

Regarding allegation, "Resident medical equipment was missing functional parts." LPA interviewed S1, S2, S3, S4 and also reviewed R1's service plan. LPA found that R1 went to the hospital, and returned using the wheelchair for mobility. R1 chose to utilize the wheelchair without the footrests. Therefore the above allegation is UNSUBSTANTIATED. Continued on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

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 18-AS-20220630090754

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: 07/08/2022

NARRATIVE

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Regarding allegation, "Staff speak inappropriately to resident in care." LPA spoke with R2, S2, S3, and S4 and through interviews obtained determined allegation was UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted and a copy of this report was discussed with and provided to S1 along with copies of the LIC9099-C, and LIC811.

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

LIC9099 (FAS) - (06/04)

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