374604274-2-13-2024-08-AS-SJAB-D2XRWH-20240301122306

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 02/13/2024
Date Signed: 02/13/2024 11:39:18 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/24/2020 and conducted by Evaluator Iby Strong

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20201124123344

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: 89	DATE:	02/13/2024
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Executive Director Marie Hill		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Facility staff dropped resident during transfer.
Facility did not notify responsible party of staff dropping resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Iby Strong conducted an unannounced visit to deliver findings for the above-mentioned allegations. LPA identified herself and discussed the purpose of the visit with Executive Director Marie Hill.

On November 24, 2020, Community Care Licensing (CCL) received a complaint alleging Resident 1 (R1) was dropped by facility staff and such fall was not reported to the responsible party. During the investigation, the Department collected pertinent resident records as well as facility documentation and conducted interviews. According to R1’s Physician Report, dated September 25, 2020, R1 has a mild cognitive impairment, is non-ambulatory, and requires minimal assistance with activities of daily living. R1’s Plan of Care dated October 10, 2020, states R1 requires assistance with transfers with verbal cueing.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: (619) 481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

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 08-AS-20201124123344

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: VISTA DEL LAGO MEMORY CARE	FACILITY NUMBER: 374604274
	VISIT DATE: 02/13/2024

NARRATIVE

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According to allegation, three weeks prior to November 24, 2020, R1 was dropped by an unnamed caregiver during a night shift. Interview with staff present on or around the timeframe mentioned stated they were unaware of R1 being dropped. Interview with outside source revealed that there were no instances of R1 being dropped. Interview with outside source also revealed that there was no injury on R1 to determine R1 was dropped. Records collected did not reveal any additional information to corroborate allegation.

It was also alleged that facility staff did not report R1 being dropped to R1’s responsible party. Interviews with staff present on or around the timeframe mentioned stated they were unaware of R1 being dropped therefore it was not reported. Interview with outside source revealed there was no evidence to corroborate resident was dropped. Additionally, there were no records available to corroborate allegation.

Based on Department’s interviews, and record reviews there is not a preponderance of evidence to prove alleged violation occurred, therefore the allegation is unsubstantiated. An exit interview was conducted with Executive Director Marie Hill , to whom a copy of this report, and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISOR'S NAME: John Rante	TELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Iby Strong	TELEPHONE: (619) 481-0846
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC9099 (FAS) - (06/04)

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