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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 11/21/2022
Date Signed: 11/21/2022 12:41:21 PM

Unfounded


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
11/16/2022 and conducted by Evaluator Tricia Danielson
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20221116131339
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: 94DATE:
11/21/2022
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Johnathan Thomas, Executive DirectorTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Facility staff takes resident’s belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to intiate an investigation into the allegation listed above. LPA met with Executive Director (ED) Johnathan Thomas and explained the purpose of today's visit. During today's visit, LPA interviewed Resident #1(R1), one(1) staff, one(1) witness, toured R1's room, and reviewed pertinent documents. Regarding the allegation "Facility staff takes resident's belongings", it was alleged that when staff are taking R1's pants to be laundered, they are keeping the pants for themselves and therefore, R1 is now missing five(5) additional pairs of pants. Records reviewed revealed R1 had approximately five(5) to six(6) pairs of pants at the time of their admission in November 2021. During today's visit, LPA observed four(4) pairs of pants hanging in R1's closet. R1 was also wearing a pair of pants. Interview conducted with Staff #1(S1) revealed R1 had presented two(2) pairs of pants to be laundered earlier today. Interview conducted with R1 revealed no staff has been observed wearing R1's pants and all clothing items are marked with R1's name. Interview with R1's responsible party indicated R1 had approximately seven(7) pairs of pants at admission and not the number alleged of eleven(11) to twelve(12). This agency has investigated the complaint alleging "Facility staff takes resident’s belongings". We have found that the complaint was UNFOUNDED, (CONTINUED ON LIC9099-C)
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
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 2
Control Number 18-AS-20221116131339
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: 11/21/2022
NARRATIVE
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(CONTINUED FROM LIC9099)
meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted and a copy of this report was provided along with LIC811- Confidential Names List.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Tricia DanielsonTELEPHONE: (951) 565-7254
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2