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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604274
Report Date: 04/18/2024
Date Signed: 04/18/2024 10:59:27 AM

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
11/06/2020 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20201106075652
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: 92DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Executive Director, Marie HillTIME COMPLETED:
11:05 AM
ALLEGATION(S):
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Licensee not meeting the resident's care needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA met with Executive Director, Marie Hill.

During the investigation, records were reviewed, and interviews conducted with staff and outside sources. It was alleged the licensee was not meeting the needs of Resident #1 (R1). It was reported R1 was not kept clean, urinated on themselves, and was left in soaking wet clothing for an extended period, and was in pain from an untreated Stage II pressure injury. R1’s Physician’s Report dated 09/25/20 indicated R1 was incontinent of bladder, required assistance with bathing, dressing/grooming, and medication management. R1’s Service Plan dated 10/14/20 indicated R1 required assistance with showers on Tuesdays and Fridays, occasional assistance with transfers, and medication management. The Service Plan also reflected R1 was continent of bladder but required assistance with bowel incontinence. On 11/02/20 a medical professional observed R1 to be unkempt, appeared as though they hadn’t showered in a while as their hair was dirty, and there was black dirt on their feet. Continued on an LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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 5
Control Number 08-AS-20201106075652
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: 04/18/2024
NARRATIVE
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The medical professional also observed R1 was favoring the left side of their body due to a painful Stage II pressure injury located on their right heel. The Medical professional’s interview confirmed they contacted the facility regarding the pressure injury, but the facility stated they did not have knowledge. The facility provided basic services to R1 that included observations of R1.

R1’s shower schedule for November 2020 reflected initials on the days R1 was provided showers. On 11/17/20, 11/20/20, 11/24/20, and 11/27/20 there were no initials to verify showers were provided or documentation to indicate R1 refused showers. The facility is required to meet the basic needs of the residents to include ensuring the residents are kept clean. Facility’s documentation of bathroom assistance reflected it was PRN, as needed. However, staff initials verified they assisted R1 with bathroom assistance for eight (8) of the thirty (30) days in November 2020, which indicated R1 required assistance. Staff interviews confirmed R1 was a full assist with toileting and diapers. Further staff interviews revealed finding R1 in soiled diapers on multiple occasions. Outside source interviews confirmed observing R1’s needs not being met due to being unkempt with dirty hair and black dirt on their feet.

Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Marie Hill whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20201106075652
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: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2024
Section Cited
HSC
1569.312(b)
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Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services:(b) Assistance with instrumental activities of daily living in the combinations which meet the needs of residents. This requirement is not met as evidenced by:
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Executive Director provided recent proof of training regarding caregiver job description, caregiver training checklist to include activities of daily living and observations of residents. In addition, the facility has another training scheduled for 04/23/24 and will be ongoing monthly. POC corrected.
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Based on interviews and record review, the licensee did not ensure resident needs were met for 1 out of 89 residents in care [R1] which posed a potential health and safety risk to persons in care.
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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: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
11/06/2020 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20201106075652

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: 92DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Executive Director, Marie HillTIME COMPLETED:
11:05 AM
ALLEGATION(S):
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2
3
4
5
6
7
8
9
Licensee violated the resident's personal rights
Licensee not following physician's orders
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above-mentioned allegations. LPA met with Executive Director, Marie Hill.

During the investigation, records were reviewed, and interviews conducted with staff and outside sources. It was alleged the licensee violated the resident's personal rights. It was reported staff were saying derogatory words towards Resident #1(R1) such as calling them fat. Staff interviews confirmed they did not use any derogatory words towards R1. Outside source interviews revealed they did not witness R1 being called fat.
It was also alleged the licensee was not following physician’s orders for R1. It was reported R1 was requesting a specific pain medication and it was not being provided. R1’s Physician’s Report dated 09/25/20 indicated R1 required assistance with medication management. R1’s Service Plan dated 10/14/20 indicated R1 required assistance with medication management. Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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 5
Control Number 08-AS-20201106075652
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: 04/18/2024
NARRATIVE
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R1’s medical record reflected they were prescribed a specific pain medication on 10/16/20, a PRN, as needed. A review of R1’s Medication Administration Records (MARs) for October 2020 indicated the medication was dispensed on 10/17/20 for moderate pain. MARs for November 2020 indicated the specific PRN medication was dispensed on 11/02/20 for moderate pain and 11/06/20 for severe pain. The facility was dispensing the medication as needed. Outside source interviews revealed a medical professional contacted the facility to inquire about the pain medication being dispensed. The medical professional reported the facility stated R1 was not complaining of pain, and it was unknown if staff were asking R1 if they were in pain. According to medication documentation, the licensee followed the physician’s order and provided as PRN, as needed. Staff interviews confirmed medications were dispensed as prescribed.

During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Marie Hill whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 219-9755
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5